BANGKOK — A mobile, constantly growing population already makes for a challenging health care delivery environment. Add monsoon rains, makeshift settlements without food, clean water, or latrines, and hilly terrain with few roads in and out to access inhabitants in need of medical care. That’s the situation the World Health Organization mobile health teams and other health care providers are facing after the influx of Rohingya asylum seekers to Bangladesh’s beachside town of Cox’s Bazar.
Over the past month, 440,000 Rohingya have arrived in Bangladesh from Myanmar’s Rakhine state amid an outbreak of brutal and targeted violence. The rapid increase in population coupled with low vaccination rates (many Rohingya had long been denied access to medical care in Rakhine) adds up to create a high risk of infectious disease outbreak.
WHO has deployed 40 team members to Cox’s Bazar to assess and scale up health services, and is doing its best to support existing overwhelmed medical facilities and complete a first-round measles vaccination campaign. Between August 25 and September 17, Médecins Sans Frontières clinics alone received a total of 9,602 outpatients, 3,344 emergency room patients, 427 inpatients, 225 patients with violence-related injuries, and 23 cases of sexual violence, according to a September 21 MSF release.
WHO representative to Bangladesh Dr. N Paranietharan — who has both a medical and emergency coordination background — is on edge considering the perfect storm for a massive disease outbreak, but hopeful that an active government, a reformed WHO emergency response, and a talented in-country team can help responders and partners stay ahead of a potential public health disaster.
The WHO has released $175,000 in emergency funding from the South-East Asia Regional Health Emergency Fund, and Paranietharan has reallocated $400,000 from the Bangladesh country office and been granted an additional $500,000 from a WHO headquarters contingency fund.
But just over $1 million won’t be enough, he said, citing $5 million as the figure he’ll likely need to scale up health services while also improving coordination to respond to potential disease outbreak in Cox’s Bazar in the next six months.
“If we have any major outbreaks, this money will go in two to three months, very quickly,” he said.
Bangladesh, a country prone to flooding and landslides, is no stranger to emergencies and has a robust preparedness plan, Paranietharan said. The country is still responding to August’s devastating monsoon floods that covered one-third of the country and affected more than 8 million people.
“Bangladesh is quite used to that,” Paranietharan told Devex of natural disaster response. “But an emergency of this scale, in three sub districts of one district, is unprecedented … It’s in a very concentrated area with limited facilities.”
His most immediate concern is provision of potable water points and sanitation facilities for the countless makeshift settlements springing up, but especially in the 2,000-acre Kutupalong extension site. That area was allocated to new arrivals by Bangladesh authorities and is named for the neighboring Kutupalong camp, which has housed Rohingya asylum seekers since the 1990s. Meanwhile, Kutupalong and another pre-existing settlement Balukhali “have merged into one densely populated mega-settlement of nearly 500,000 people, making it one of the largest refugee concentrations in the world,” according to MSF.
“There’s a dire need to have scaled-up, appropriate WASH interventions in order to prevent diarrheal diseases,” Paranietharan said.
WHO has tested the water quality at the extension site, where desperate newcomers are already drinking murky liquid from puddles and hand-dug wells. The results have health care delivery teams “incredibly concerned” about diarrheal diseases, especially cholera, Paranietharan said.
“The water they are drinking is not safe,” he said. “When you have very high turbidity water like this, your water purification tablets won’t work.”
Strong partners in WASH, such as Action contre la Faim and UNICEF, are taking action, he added, and the government is mobilizing supplies to build latrines and set up safe water collection points: “It’s not that it’s not possible, but it’s not going to happen in a few weeks’ time — maybe in a few months,” he said.
While Paranietharan is concerned about cholera, he is more confident that there won’t be a measles outbreak thanks to quick action from the Bangladesh health ministry and other partners to conduct a mass measles, rubella, and polio immunization campaign within weeks of the first thousands of Rohingya across the border.
“This is one of the very few … or maybe the only emergency I’ve been involved with where we managed to do a mass vaccination campaign on such short notice,” he said. As of last Friday, the campaign had vaccinated nearly 70,000 children, with the goal to reach 150,000.
Paranietharan credits part of the swift response to the strong will of the Bangladesh government, pointing to the fact that the Bangladesh director of health services was with him in Cox’s Bazar last week to make decisions about preparedness, create a contingency plan for potential cholera outbreak and identify sites if treatment centers are urgently needed.
“This is fantastic because in many countries I’ve worked in, either you don’t have an active government or you have a strong government that is not open to working with you,” Paranietharan said.
The other recognition for what he sees as a strong response to a complex emergency thus far goes to WHO’s revised health emergencies program and his own experienced in-country team, he added. Paranietharan has been recruiting staff for years “in a way expecting that we would have another outbreak in the country or potentially an earthquake, so I was recruiting the right people to manage it,” he said. “This is not a situation we were predicting, or expecting, or even planning for. But it’s good to have a team with a good mindset and skillset to quickly respond.”
The new WHO health emergencies program, borne in response to criticism of the pace of WHO’s response to the Ebola outbreak in West Africa in 2014, also helped provide his team with a solid emergency grading system, performance benchmarks, and predictable health financing, Paranietharan said.
Still, “one small event could lead to an outbreak that may be the tipping point between a crisis and a catastrophe,” said Robert Onus, MSF emergency coordinator, in the September 21 release. MSF has already prepared an isolation unit in the Kutupalong medical facility to rapidly contain any suspected or identified cholera or measles cases.
WHO, in coordination with partners and the government, plans to set up 12 fixed health care sites in the new extension camp, with 24 mobile teams supporting them.
“As people settle in a defined area, it will be easier to provide services to them,” Paranietharan said. “But it’s still too early to say whether we’ve gotten ahead of an outbreak or not.”
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