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The Prevalence and Consequences of COVID-19 to Rohingya Refugees in the Kutupalong Camp, Bangladesh

Jade Patel, EMH2

March 15, 2021


Kutupalong, a refugee camp located in Ukhia, Cox's Bazar, Bangladesh, is a hotspot for Coronavirus (COVID-19) due to the chronic overcrowding, unhygienic conditions, and lack of health information. With the ongoing mass migration of the Rohingyas who are fleeing Myanmar to escape persecution and the ominous threat of a COVID-19 outbreak, Kutupalong is critically at threat of a rise in positive cases and increased mortality rates. Persecution began in 2017, after the Government of Myanmar, a predominantly Buddhist country, denied the Rohingya citizenship and excluded them from the 2014 census due to their Islamic faith. In response, the Arakan Rohingya Salvation Army(Arsa) militants launched deadly attacks on police posts in protest for change.[1] Within the first month of fighting, at least 6,700 Rohingya, including 730 children under the age of five, were killed, and 400 villages were destroyed. Despite the denial of the campaign against the Rohingyas, they left Myanmar to seek refuge at Kutupalong, one of the two government-run refugee camps in the region.[2]Kutupalong, the largest refugee camp in the world, is severely overcrowded relying on makeshift settlements to accommodate for more forcibly displaced people. The rapid growth of these settlements is creating a merging with surrounding refugee camps such as Ghumdum, Balukhali, and Thangkhali. Out of the 1 million Rohingyas that fled, 860,175 are sheltered within Kutupalong.[3]These current conditions and limited access to medical care put the Rohingyas at grave threat from a COVID-19 outbreak.


One of the many settlements in Kutupalong, Bangladesh[4]


At present, Bangladesh has recorded 554,000 active cases of COVID-19 and 8,502 deaths. The high COVID-19 activity begs the assumption that refugee camps are a prime hotspot, however, by March 2021, Kutupalong has 406 recorded cases out of the 30,561 tests performed, and 10 fatalities.[5] The number of cases compared to the population and conditions suggests that the reported cases are very low to what would be expected. Different reasons could explain the few cases detected. Aside from the disproportionate tests, experts suggest that the accuracy of the reported cases may be low as the Rohingya refugees with symptoms are not coming forward to get tested. Language barriers and lack of access to health information could be a causal reason, since the banning of internet coverage by the Bangladesh Government in September 2019.[6] Lack of internet isolates the Rohingyas, decreasing access to health information such as where and how to get tested and treated. Controversially, it is suggested that people are not getting tested because they fear deportation. It has been suggested that camp administration may also be playing a part in the low recorded cases by not fully disclosing the number of people infected. This is not proven but could be a measure to protect the refugees in Kutupalong from deportation. Camp rumors add fuel to fear, believing that anyone who tests positive for COVID-19 will be killed to prevent others from becoming infected, in the name of treatment.[7] The Rohingyas also fear quarantine and separation from their families. There is no evidence to suggest these rumors are true but to counteract the fear, refugees are choosing not to seek treatment. Not seeking treatment threatens the Rohingya's health and lives. It is crucial that Kutupalong staff, including volunteers and health workers, advocate that treatment is safe and provide sufficient health information on how and where to get tested.

Evidence highlights the average living space is 10 meters squared, used to accommodate up to 12 people. With less than a square meter per person, this removes the option to self-isolate.[8] With this many people in one place, an outbreak of COVID-19 would spread rapidly, and infect a high number of people in a short time, having the potential to lead to thousands of fatalities.[9] Social distancing is also extremely challenging due to the camp’s high population density. The camp pathways are 2 meters (approx.) in diameter, heavily used, and permanently clogged by those searching for food. Social distancing is not advocated amongst the Rohingyas as they believe it is up to fate if they contract COVID-19. This belief, along with the need to seek food and facilities, could be a reason as to why they are remaining in close contact with each other, increasing touch and aerosol transmission.[10] Queueing with masses of people to use the same facilities or supplies increases the risk of spreading COVID-19. Without sanitization or frequent cleaning, the virus can spread from person to object and object to another person. If this cycle is continually repeated, this will increase the number of active cases which may go undetected without testing.


Kutupalong Shelters and Paths[11]


The absence and disproportion of COVID-19 tests in Kutupalong disallow for an accurate number of positive cases to be identified. This means the recorded figures of positive cases are not representative of the camp population, but only to those who have been tested and received a positive result. With 30,561 tests, this equates to only 4% of the Rohingya population tested for the virus. Thousands of active cases could be going undetected, equating to an uncontrolled and unpredictable outbreak. Fortunately, the majority of Rohingyas are in good health, despite preexisting illnesses and intermittent outbreaks of measles and diphtheria. However, if the poor conditions at Kutupalong continue, they will be a prominent causal factor as to why and how the virus could spread. Correlations between high-density populations and the opportunity for diseases to originate and spread are not uncommon. Even with good health records, an outbreak can still happen. For example, in 2020, Kutupalong became host to an acute respiratory infection (ARI) and within 12 months, reported 175,000 cases, strongly indicating that COVID-19 could spread just as easily. Comparing the high infection figures of the ARI to the low COVID-19 cases suggests that COVID-19 infections may be going undetected or unacknowledged. Efforts to tackle spread include maintaining good hygiene and sanitation, specifically hand washing and cleaning high-touch objects such as toilet seats, door handles. A significant issue in Kutupalong is the lack of basic sanitation, making desired hand hygiene close to impossible. With very limited access to clean water and restricted access to hand sanitizer, the Rohingyas are unable to maintain a satisfactory level of cleanliness to decrease the risk of contracting the virus. Due to issues with resource availability, it is near impossible to make sure each refugee has plentiful hygiene provisions. In response, the World Health Organization (WHO), has begun distributing more soap around the camp and has conducted training on infection control for health workers and facility staff who work within the Rohingya camps.[12]


Refugees and recently displaced people tend to have a higher rate of preexisting health issues due to the impacts of war, disease, and famine. Untreated conditions such as diabetes, hypertension, and asthma can make the refugees susceptible to health deterioration and diseases. Studies show that hypertension and diabetes are common within the Rohingyas population of the camp, increasing their vulnerability to contracting and transmitting viruses, such as COVID-19.[13] Before the pandemic, refugees were not allowed outside of the camp for security reasons, leaving mobile clinics as the only source of healthcare.[14] Healthcare resources and hospitals within the camp are already exhausted. The impact of the pandemic is making these resources even more scarce, with not enough provisions to treat all refugees that require medical assistance.


Inside Kutupalong: Camp Hospital[15]


Kutupalong is currently dealing with an outbreak of diphtheria alongside the pandemic. Hospital camps are not equipped to deal with another outbreak, such as COVID-19. Multiple infectious diseases, combined with weakened immune systems make the Rohingya refugees susceptible to COVID-19 and could lead to multiple epidemics within the camp at once. Diphtheria is transmitted the same way as COVID-19, through respiratory droplets, and both are highly transmissible. One highly contagious illness, if not contained and controlled, is enough to cause devastation amongst the camp, but with two major outbreaks, fatalities will inevitably occur. Access to healthcare assistance will become near to impossible as the hospitals are already stretched and would not be sustainable to deal with two outbreaks at one time. Since positive cases of COVID-19 began in Kutupalong, the virus has taken priority and has postponed diphtheria and other treatments. Consequently, by not being able to continue pre-existing treatments, poor health is prolonged which could be fatal. Whilst diphtheria has a vaccine and cholera has a treatment plan, COVID-19 treatment, such as the vaccination program is still to be confirmed. An outbreak could potentially exhaust medical resources, overwhelm healthcare workers and camp hospitals within 58 days, consequently, leading to a rise in deaths from other infectious diseases, such as ARI’s and diphtheria.[16]


In perspective, a virus outbreak exposes the Rohingya to a prevalent threat, presenting them with a choice of either staying in Myanmar and risking persecution or fleeing to a “safe” refuge where the threat of illness could be a killer. As a result, the Rohingya are left with limited choices. The consequence of each choice signifies the position the Rohingyas are in, and that either option jeopardizes their safety. Their homeland conflicts and their villages have been destroyed, making repatriation a long-lost hope. The increasing population in Kutupalong exposes the Rohingya to a wide range of health threats, and an outbreak of COVID-19 has the potential to fatally impact a significant number of people.


March 24, 2020, saw the first COVID-19 case in Cox’s Bazar, and in efforts to contain the spread, the government initiated a camp lockdown. Kutupalong access was restricted, leaving only emergency food supplies and medical support to be allowed in. Not only is a lockdown challenging in high-density populations, but it puts the Rohingyas in a threatening situation from increased crime, abuse, sexual assault, and deterioration of mental health.[17] Those still seeking refuge are refused entry, increasing the total of displaced people seeking asylum, crossing borders, and not being able to seek shelter and protection. Bangladesh, like many other countries, is facing a domestic economic crisis and cannot afford additional efforts to offer aid to those living in the camps or on the borders. Aid has already been disturbed but is continuing to decrease as the pandemic draws on.[18]


The COVID-19 measures that are implemented in other countries are not suitable or realistic for Kutupalong. The Rohingyas are left in a vulnerable position and cannot easily combat the transmission of the virus. However, volunteer health workers are being deployed in the camp to teach and provide guidance on social distancing, and how to reduce the spread of the virus. WHO is also working with the camp by offering advice on measures adapted to suit the circumstances in the camp. Measures include ensuring Kutupalong is equipped for a COVID-19 outbreak such as providing washing stations, disinfecting toilets, soap distribution, providing face covering, and educating the refugees on the threat of the virus. Despite the measures, only 10,000 masks have been made available, 9000 toilets disinfected and 500,000 bars of soap distributed, protecting less than half of the Rohingya population in Kutupalong. Lack of equipment and resources suggests other measures need to be put in place such as a camp lockdown. It is crucial that when implementing a camp lockdown, that this does not increase secondary safety threats.[19] Bangladesh authorities have built barbed wire fences around the camps to stop expansion and reinforce the entry restrictions. Whilst the Rohingyas await the COVID-19 vaccination, health workers are trying to reintroduce and continue treatment for preexisting conditions, alongside treating positive cases, to increase the health of the camp and make room for those who will need to access the hospitals if an outbreak occurred. Cholera, measles, and diphtheria vaccination and inoculation programs are underway to increase immunities and offer protection against viruses. Ongoing fundraising campaigns are critical to try and increase the revenue of the non-governmental organizations (NGOs) and start to gain extra resources.


Despite the measures, the prevalence and the consequences of an outbreak are immeasurable and unpredictable. Day-to-day activities change within Kutupalong depending on resource availability. Aside from food insecurity, healthcare resources are an issue within the camp that can constantly change depending on a range of factors such as how many people are needing assistance and how many people are seeking resources. Despite the lockdown, more people are arriving at the camp, making this increasingly overcrowded. With more refugees arriving, this means the limited healthcare resources must be shared further restricting treatments. Spreading awareness of health concerns within Kutupalong is a crucial starting point to deter from inevitable threats. Campaigns and a volunteer program could be created to help vaccinate and reduce the risk of a mass COVID-19 outbreak. More sanitation supplies, face masks, and better hygiene facilities are necessary to reduce virus transmission. Management plans need to be revised, to successfully allow for social distancing, with the potential of isolation pods. Resource management is also crucial to make sure those who need tests, and other medical attention are getting the right provisions. Such as those already in treatment having access to medications, along with those who contract COVID-19.


CTG looks to detect, deter, defeat issues that compromise and are concerning to health, such as pandemics. The EMH2 team specifically focuses on analyzing the importance of positive and negative health and hazards impacts. The transmission of COVID-19 across the globe has been monitored by the team since January 2020. The EMH2 team recommendations are tailored to those on the operational level such as managers and personnel who are tasked with keeping the day-to-day operations, agencies, organizations, companies, those working within the camps to protect, and try to reduce the risk of outbreaks. Our recommendation is to implement a screening process, as exemplified within the UK, to make more tests available to those who need them, to be able to accurately record the cases in camp. Increased advocacy is also key to make people aware, and join campaigns that can help relieve the COVID-19 issues within refugee camps, along with supporting camp hospitals with medications and sufficient supplies. Continuous campaigns to increase volunteers and aid workers are necessary to help with health administration in the camps. With more volunteers, this allows a greater number of refugees to access health information and support in the hope of decreasing the risk of a COVID-19 outbreak. The EMH2 team will continue to monitor the spread of COVID-19 within refugee camps, specifically Kutupalong, and follow all important developments. In conclusion, the EMH2 team strongly agrees with WHO, and advocates: “public health professionals and organizations should act now to prevent the spread of COVID-19 in refugees whose vulnerabilities place them at great risk of mortality.”[20]

________________________________________________________________________ The Counterterrorism Group (CTG)

[1] Myanmar Rohingya: What you need to know about the crisis, BBC, January 2020, https://www.bbc.co.uk/news/world-asia-41566561

[2] Kutupalong Refugee Camp, Wikipedia, February 2021, https://en.wikipedia.org/wiki/Kutupalong_refugee_camp

[3] “Rohingya refugees at high risk of COVID-19 in Bangladesh,” The Lancet Global Health, June 2020, https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30282-5/fulltext

[4]View of the sprawling Kutupalong refugee camp near Cox’s Bazar, Bangladesh” by DFID, licensed under Creative Commons Attribution 2.0 Generic License

[5] Rohingya Crisis Situation Report #4, World Health Organization Bangladesh, March 2021, https://reliefweb.int/sites/reliefweb.int/files/resources/who-cxb-situation-report-4.pdf

[6] The danger of disease in the world’s largest refugee camp​​​​​​​, The Interpreter, April 2020, https://www.lowyinstitute.org/the-interpreter/danger-disease-world-s-largest-refugee-camp

[7] Rohingya refugees at high risk of COVID-19 in Bangladesh, The Lancet, June 2020, https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30282-5/fulltext

[8] Ibid.

[9] Ibid.

[10] Ibid.

[11]View of the sprawling Kutupalong refugee camp near Cox's Bazar, Bangladesh” by DFID, licensed under Creative Commons Attribution 2.0 Generic License

[12] Coronavirus closes in on Rohingya refugees in Bangladesh’s cramped, unprepared camps, The Conversation, March 2021, https://theconversation.com/coronavirus-closes-in-on-rohingya-refugees-in-bangladeshs-cramped-unprepared-camps-135147

[13] Hypertension and Diabetes Assessment in the Rohingya Refugee Population and in the Host Communities in Bangladesh, Clinical Trials, November 2020, https://clinicaltrials.gov/ct2/show/NCT04307875

[14] Providing healthcare in the camps of the Rohingya, The BMJ Opinion, December 2018, https://blogs.bmj.com/bmj/2018/12/31/providing-healthcare-in-the-camps-of-the-rohingya/

[15] “UK Emergency Medical Team paediatric nurse Becky Platt pictured wearing protective equipment in a specially constructed diphtheria treatment clinic in the Kutupalong refugee camp, Bangladesh, January 2018” by DFID, licensed under Creative Commons Attribution 2.0 Generic License.

[16] “Refugees and COVID-19: achieving a comprehensive public health response.” World Health Organization, 2020, https://www.who.int/bulletin/volumes/98/8/20-271080/en/

[17] Sexual Violence,Trauma, and Neglect: Observations of Health Care Providers Treating Rohingya Survivors in Refugee Camps in Bangladesh, Relief Web, October 2020, https://reliefweb.int/report/bangladesh/sexual-violencetrauma-and-neglect-observations-health-care-providers-treating

[18] “Fragmented health systems in COVID-19: rectifying the misalignment between global health security and universal health coverage,” The Lancet, December 2020, https://www.thelancet.com/article/S0140-6736(20)32228-5/fulltext

[19] Coronavirus closes in on Rohingya refugees in Bangladesh’s cramped, unprepared camps, The Conversation, March 2021, https://theconversation.com/coronavirus-closes-in-on-rohingya-refugees-in-bangladeshs-cramped-unprepared-camps-135147

[20] Ibid.

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