Interviews

Ensuring Well-Being: Health Interventions During a Humanitarian Crisis

Courtesy of UNICEF

In conversation with FARIA SELIM Spokesperson, Unicef

The humanitarian situation of Rohingya refugees in Bangladesh remains dire, with some 647,000 newly arrived refugees since 25 August 2017, totalling up to 2,000 persons arriving each day at various entry points along the border.
Upon arriving at the site, Faria Selim witnessed a sea of tents, “I knew that these plastic structures were homes, hospitals, and shelters for the people. However, I was greeted by the grim reality of the situation.” She met a shivering woman upon entering the tent; not understanding her words, Faria asked her driver to translate for her, and he explained that she was in labor.
“I wanted to take her to the hospital. As my colleague and I were trying to stop a car and as we were working out the means of action with him, she went into labor,” details Faria. Unfortunately, the woman had delivered a still born baby. “The baby’s white complexion and lack of movement indicated that the child was stillborn. She went on to tell me that she had lost her husband after trekking across unknown lands for 8 to 10 days. She did not know if he was alive.”
Stories such as these were all too common in the camp. There were women perched on roadsides not knowing where to go amongst this massive influx. “I spoke to a woman who had given birth during her journey here. She had her mother-in-law to assist her and no one else. Fortunately, her child had survived, but these new mothers and pregnant women were giving birth without any security of their own life.”

Courtesy of UNICEF

MOTHERS AND CHILDREN IN NEED
We found an estimated 564,000 people are in urgent need of nutrition services. Among them, 16,695 children under 59 months need treatment for Severe Acute Malnutrition (SAM); 198,868 children aged 6-59 months need Vitamin A supplementation; 50,780 pregnant and lactating women (PLW) need counselling on infant and young child feeding practices in emergencies.
Since 25 August, a total of 168,480 children under the age of five have been screened for malnutrition and, out of them, 9,026 children were identified with SAM. Among them, 8,720 children are receiving treatment.
We also found that many expecting mothers or breastfeeding women were not even equipped with the information to handle their children. 19 of our nutrition centers opened a separate wing that focuses on aiding pregnant women and lactating mother. We counsel them on infant child feeding. Furthermore, there is a breastfeeding corner that is teaching a lactating mother how to feed their babies. It also provides a safe place for them to feed their children. Among the pregnant and lactating women, 30,847 received infant and young child feeding (IYCF) counselling, along with critical information to reducing undernutrition among infants and young children. In addition, 228,269 children between 6-59 months have received vitamin A supplementation and 5,606 children between 6-23 months of age received micronutrient powder (MNP) supplementation. In this case, we want the women of the community to have the necessary knowledge to support one another.

A COOPERATIVE COMMUNITY
Our centers are creating behavior changes because good hygiene practices reduce the disease state. The centers teach them simple hygiene matters such as washing their hands before eating and after using the bathroom. They also offered information as to where they can avail medication and medical services through other institutes. Upon entering the site, we realized that the community leader (majhi) had a tremendous influence on the people. We prioritized training them to disseminate information. These leaders supported our vaccination initiative. After we witnessed the effectiveness of that campaign, we worked with majhis on vaccination campaigns, health services, and child protection issues including creating awareness for child trafficking. These individuals are a source of empowerment for a community.
Diphtheria cases have been increasing rapidly in camps. There is an urgent need for dissemination of relevant information regarding prevention, treatment and management of diphtheria. During the past week, UNICEF facilitated reaching out to about 217,488 people with critical and life-saving messages through various channels. A total of 200,000 listeners were also reached through key messages on psychosocial support, Child Protection, gender-based violence (GBV) and human trafficking issues through Bangladesh Betar, Cox’s Bazar and Radio NAF, with technical support from BBC Media Action. A total of 442 wind up radios were distributed to local partners for use in Child Friendly Spaces, learning centres and adolescent groups.
In 8 information centres, a total 767 feedbacks, queries and complaints were recorded this week. Moreover, through Model Mothers, about 16,000 people were reached in a week with life-saving messages on various issues including hygiene promotion, health and nutrition, safe water and sanitation. Around 108 teachers and partner staff were provided with training on interpersonal communication and key messages. Out of this, nine IFC staffs were given hands on training on the database system related to record keeping and reporting on IFC activities. Over the past week, a total 67 majhis and imams participated in advocacy meetings from different camps where discussion on hygiene promotion, prevention of diarrhoea, cholera and pneumonia, basic nutrition, child protection and menstrual hygiene management (MSM) issues were discussed.
The majhis and imams will disseminate the key messages to communities in respective blocks and Friday prayers at mosque. Involvement of Imams in disseminating messages on menstrual hygiene in mosque and communities is really a challenge that PULSE has initiated first time in the camps with technical support from UNICEF. Through community dialogues, around 654 people were reached and the topics covered were personal hygiene, child protection and nutrition.
An 800-CMV Network is being set up to contact families and discuss cross-cutting life-saving messages with them. This network is being operationalized in partnership with national NGO BRAC. This network is an addition to the already existing 80 Model Mothers and youth volunteers that were attached with the Information and Feedback Centres (IFCs). So far, the recruitment of 22 POs and 80 CMMs are in process. Starting on 10 December 2017, briefing session on Diphtheria and Measles Prevention will be conducted for CMMs, subsequently followed by formal induction training later during the month.

Courtesy of UNICEF

SAFE WATER AND HYGIENE PRACTICES: STOPPING THE SOURCE OF CONTAMINATION
The WASH (Water, Sanitation, and Hygiene) system is the major concern in the area because of the alarming rate of acute watery diarrhea. According to the Mortality and Morbidity Rate, the percent of E. coli in the region is an alarming 82%. We have provided safe drinking water for 212,800 since the start of the influx. We have recently signed an MOU with the government and army to build 10,000 latrines. Our latrines adhere to international standards because we understand that lack of these provisions allows for the circulating water-borne diseases. 300,000 people have been provided with necessary sanitation so far.
We have also enabled health practices by holding orientations on hygienic practices in our information and feedback centers, learning centers, and child-friendly spaces. Additionally, we have distributed around 137,000 hygiene kits. These kits contains detergent powder, soap, and pitchers and jugs for containing water, along with nappies, sanitary napkins, towels and sandals. Our understanding is that teaching these people employ these matters in their practices will create hygienic practices that last.
UNICEF and its partners are working to reach 450,000 people with provision of safe drinking water, emergency sanitation facilities (latrines), and hygiene kits along with culturally appropriate hygiene messages that include personal, food and menstrual hygiene.
The number of people gaining access to improved water supply and sanitation continues to increase through UNICEF’s direct support. So far, 212,800 people (47% of the target), have been reached with water supply through construction of 502 tube-wells, water treatment plants and water trucking. The construction of the 10,000 latrines by the Bangladesh Army is in progress with 3,015 latrines already completed, which brings the number of people reached with sanitation services to 313,900, representing 70% of the target population. Through UNICEF support, 7 fecal sludge management systems have been constructed in Kutupalong Mega Camp and 165 latrines were de-sludged. This is the beginning of the sludge management programme which needs to be scaled up to keep pace with demand and maintain a safe and healthy environment within the camps. The construction of 13 additional sludge plants is in progress and will be completed this month.
UNICEF has supported the construction of 700 bathing cubicles specifically for women – providing a safe and dignified bathing area for an estimated 35,000 women.
The WASH sector (sector includes all the agencies working in the WASH) has agreed to focus on the installation of deep tube-wells (more than 150 meters). There will be no more drilling of shallow wells after 31 December to avoid the risk of contamination from latrines and surface water.

PREVENTATIVE MEASURE: HEALTH INTERVENTION FOR A MORE RESILIENT FUTURE
The health needs of the refugee population are overwhelming with up to an estimated 348,000 children under age 15. These children are in need of life-saving interventions through community-based activities such as vaccination campaigns. The risk of communicable disease outbreaks remains very high given population densities inside the camps and the severe lack of adequate safe water and sanitation.
During a time where vaccinations are a very natural part of an infant’s life, the fact that such a vast population is unaware of the necessity of vaccination to prevent these diseases before they even occurring is mandatory. With the high risk of measles during such emergencies, UNICEF, WHO and the Government of Bangladesh rolled out two rounds of measles and rubella (MR) vaccination campaign, between September and November. The number of new arrivals has increased since the first MR campaign, which also had challenges reaching out to all children in view of movement of people within the camps and settlements.
The increase in measles cases has prompted the Government and UN partners to step up immunization efforts in overcrowded camps and makeshift shelters close to the border with Myanmar. Wide scale vaccination campaigns are urgently required. In total in two rounds, 475,299 children between six months and 15 years were vaccinated against MR. Additionally, children received bivalent oral polio vaccine (bOPV) and a dose of Vitamin A to help prevent measles related complication. Additionally, Government is introducing accelerated routine immunization for children providing bOPV, measles-rubella vaccination and tetanus toxoid (TT) to pregnant women through 32 medical camps and 70 outreach vaccination teams going from house-to-house. Also, vaccination posts at main entry points at Subrang, Shahporir Dip, and Teknaf are being established.
UNICEF worked with partners to vaccinate nearly 900,000 thousand people against cholera –the second largest oral cholera vaccination campaign after Haiti. On 12 December the Government of Bangladesh, with the support of UNICEF, the World Health Organization and GAVI, the Vaccine Alliance, launched a vaccination campaign against diphtheria and other preventable diseases for all Rohingya children aged 6 weeks to 6 years living in 12 camps and temporary settlements near the Myanmar border. Accelerated immunization will cover nearly 255,000 children in Ukhiya and Teknaf sub-districts in Cox’s Bazar, while the Government and health partners continue to increase support for diphtheria treatment and prevention.

SUPPORTING THE YOUNGEST MEMBERS
One realizes that this a children’s emergency when you witness that a majority of the arrival are children. We need to protect their futures. We must make sure that this crisis that is stealing their childhoods does not also ruin their futures. We need to reach as many children as possible with life-saving support – and to make sure that they can keep learning, playing — having as normal a childhood as possible. More than 373,800 children, 60% of the total influx since August 25, are exceptionally vulnerable. 9% are infants under one year old; nearly 5% of the newly arrived refugees are pregnant, and more than 9% are breastfeeding women. The most alarming scenario is that 3.6% of the newly arrived refugees are women headed households and 1.4% are headed by children.
Malnutrition rates among children in northern Rakhine were already above emergency thresholds. The condition of these children has further deteriorated due to the long journey across the border and the conditions in the camps. People now living in the camps are faced with an acute shortage of food and water, unsanitary conditions and high rates of diarrhoea and respiratory infections. Cases of measles have been reported.
We have 19 nutrition camps that measure and analyze the weight of incoming children so we can immediately assess nutrition and health interventions for each of them. Preliminary data suggest that the occurrence of severe acute malnutrition has doubled to 7.5% since May 2017. There are 16,981 children afflicted with it and the organizations there have divided this enormous task; UNICEF has targeted 7,500 kids alone. We determine which children are malnourished through SAM screening where if a child hand measurement is less than 11 cm they are considered to be severely malnourished. These children require therapeutic foods and further medications. They are more prone to chest congestion and acute respiratory infection; in such cases, we refer them to hospitals and provide the financial support for the necessary health interventions. Up to 90% of new arrivals have reported eating just one meal a day. Food security and malnutrition rates were alarmingly high even before the influx of new arrivals.
Cases of Severe Acute Malnutrition (SAM) can increase dramatically during emergencies, unless adequate responses are in place. Recent field visits, observations and nutrition assessments in the registered Rohingya refugee camps show a higher caseload of children with acute malnourishment. Despite the humanitarian aid that is being provided, the global acute malnutrition prevalence among children under 5 has increased in the recent months in the registered refugee camps. Preliminary data from a nutrition assessment conducted between October 22 and 28 at Kutupalong refugee camp shows a 7.5% prevalence of life-threatening severe acute malnutrition – a rate double to what was observed among Rohingya refugee children in May 2017. Prevalence of acute malnutrition among children 6-59 months exceeds the WHO Emergency Threshold (15%) in both registered refugees and new arrivals. Malnutrition rates among children in northern Rakhine state were already above emergency thresholds. The condition of these children further deteriorated due to the long journey across the border, and the conditions in the camps.
Since 25 August, UNICEF and partners have screened nearly 168,400 children under-five for malnutrition. Among them, 9,026 children were found with Severe Acute Malnutrition, and UNICEF provided 8,720 children are receiving treatment. As a response to the current nutrition survey that showed increased SAM rates, a scale up strategy for nutrition is currently under development. This includes opening of four more stabilization centres, 19 new OTPs, ten blanket supplementary feeding (BSFP) programmes, ten targeted supplementary feeding programmes (TSFP) and the extension of outreach activities between November and December.
As of November, UNICEF and the Government have conducted the Nutrition Action week to increase treatment of malnutrition as well as preventive nutrition coverage. The campaign targeted all children under the age of 5 years were screened and referred, and received of Vitamin A capsules and de-worming according to their needs. At least 228,269 children aged between 6-59 months received Vitamin A capsules and more than 104,048 children aged between 24-59 months received de-worming tablets. 335,000 children and pregnant and lactating women (PLW) received micronutrient powder (MNP) supplementation. 30,847 PLW have received infant and young child feeding (IYCF) counselling, information critical to reducing undernutrition in infants and young children.

In conversation with KAOSAR AFSANA, Director, Health, Nutrition and Population, BRAC

Upon the decision that they would need to intervene in an enormous humanitarian crisis of the recent time, Kaosar Afsana and fellow Director Md Akramul Islam were the first to go to the site.
She details that even after many years in the medical school and fieldwork she had been ready for such emotional shock and psychological trauma, ‘We went to Kutupalong camp. Rohingya refugee women and men are waiting along the roadside sitting on the mud, many are moving carrying bags on the top of their head, and some are inside the makeshift shelter – 15 to 16 in one temporary plastic shelter camp. Faces and eyes are without emotion and expression, completely lost and helpless.“ She continued, “I witnessed a man lying outside one hospital with most of the skin burned off. I could not look at him a second time because I was not prepared for this magnitude of pain and sufferings.” The patient was left untreated as there was no option for treating him.
She knew that they would have to expand their services beyond the child-friendly spaces and water hygiene and sanitation (WASH) service; they would need to health interventions and psychosocial trauma counseling immediately. ”It dawned on me that he was one of the countless and helpless that had been denied basic treatment and humane treatment in his own country. The normalization of their tone as they spoke of their helplessness, displacement, and torture was what struck me most.”

Photo credit: BRAC

HEALTH WORKERS: A FORCE IN NUMBERS
Our community health workers have always been one of our greatest strengths, and this crisis was no exception. We trained 120 community health workers following the crisis, to work with our medical doctors and paramedics in the camp. They are spread across 50 of our satellite clinics and 10 of our fixed primary health care centers (PHC); we have treated 490,033 patients through our satellite clinics and 147,985 patients through our PHC. They are our primary health focal points, and they work to provide essential health services. We have treated more than 590,000 patients. Our community mobilization volunteers have made 61,711 household visits.

MATERNAL CARE AT EVERY STRETCH
With 10 fixed centers, we have established 10 maternity centers where trained midwives offer services to pregnant women. The midwives attend childbirth in the maternity centers and also at home. They check pregnant women providing antenatal care and postnatal care after delivery. The most considerable limitation of any intervention is the fact that you can only work from 9 A.M. to 5 P.M. Packing up means that the services provided in our centers are not available. Beyond that time, you are not permitted in the camp for security purpose. This time limitation poses the most significant challenge for women with labor pain. Although our maternity centers have allocated space for them to give birth, many of them are not comfortable going out of their shelter home. We have trained Rohingya traditional birth attendant to help them during these hours or refer them to hospitals if the women need urgent attention. We have developed a referral system so that emergency cases can be taken to hospitals by calling our ambulance. Our ambulance will take them to hospitals right away. Our centers have delivered 398 babies. We also focus on mothers delivering antenatal care to 20,341 women and post-natal care to 2,061.

Photo Credit: BRAC

INTERVENTION WITH SENSITIVITY
These people come from a very conservative background with traditional beliefs and practices, and for years, they did not access to healthcare in their own country – Myanmar. Health interventions, therefore, must be planned and designed in the context of their reality and understanding. The average family size in the camp is not less than 6 to 7; I’ve seen families of 19 and 21. These large families create a dangerous cycle of malnutrition and eventually untimely death. They need proper family planning program to save lives of mothers and children and save the future generation. One cannot implement an aggressive family planning program for these communities. If we reflect on our own country, family planning was not primarily accepted until the benefits were explained.
We have trained some of the women in the camps because they have the most open access to the families and can communicate most effectively. These women along with our community health workers go door-to-door to assess the size of families and group the female members according to age. They are grouped into members under 5, adolescents and females of birthing age (15-49). These girls teach the community about family planning and health care and practices that are accessible. The primary challenge in this concern is providing these women with contraceptives. We have provided family planning services to 12,536. They are not accustomed to oral contraceptives and prefer injections. The severity of the situation is one that demands for them to have this form of contraception. However, we need the major stakeholders in the refugee camps to make these injections available. Unfortunately, they also have limitations, and this mainly entails their procurement process. They must now allocate money for these provisions.

Photo Credit: BRAC

COORDINATING HYGIENE AND SANITATION
With such a vast influx settling in the region with no water and sanitation provisions, diarrhea and water-borne diseases become a primary concern. We have treated nearly 81,051 cases of diarrhea and 78,456 cases of pneumonia alone. At first, there was a lack of coordination because many organizations and NGO were building latrines too close to one another. We are more coordinated in this matter now. Our 13,120 latrines provide sanitation services to approximately 563,400 people. These people also have no access to safe drinking water. 1,265 shallow tubes wells were set up so that people have access to safe drinking water. However, to improve water quality, we educated the community and distributed halogen tablets, and at the same time, we installed 83 deep tube well. Our safe water interventions have reached 366,840 people. We understand that hygienic practices need to be implemented and this has led us to construct hand washing stations and continuous education on hygiene promotion. We have conducted 37,116 hygiene session to educate the population about healthy practices.
We also want to ensure that women and children can bath safely in one of our 3,735 bathing cubicles.

SUSTENANCE AMONGST A CRISIS
When you have such a crisis, the priority becomes feeding these people. The World Food Project (WFP) provides rice and lentil, but this is not enough. Moreover, these people do not eat lentil so you often find them trading it in for vegetables and whatever else they can find. Malnutrition is increasing at such a high rate because they have no access to a diversified diet. For now, organizations are focusing on keeping them fed. The cases of malnutrition amongst children will continue to increase if not doubled if a more diverse diet is not provided.
We focus on complementary feeding which includes children over six months to have quality food beyond breast milk for nutrition. I witnessed their resilience as a population; they have started to set up shops for vegetables and rice, which they trade or buy through the money they have earned. They are already building a community within the community.

Photo Credit: BRAC

TAKING PREVENTATIVE MEASURE: INTEGRATING IMMUNIZATION
In today’s day and age, vaccinations are a norm when any child is born. I was awestruck to see the degradation of health for the children because they have not been vaccinated in their own country – Myanmar. This lack is a testament to the conditions of the region. To control the cholera outbreak, we instantly started the cholera vaccinations. The Global Vaccine Initiative has supplied the first round of vaccines to prevent cholera outbreaks, and they are working to provide the second series within six months’ time. We are concerned with measles and diphtheria outbreaks. Suddenly, diphtheria outbreak started, again with the proactive government, NGOs and WHO and UNs’ support, the country has managed to control diphtheria. We actively participated in cholera and diphtheria control program. Now routine immunization has started where we are also actively participating. There are 279 health workers and 1,129 program staff who have trained to handle diptheria cases. 14,393 children have been vaccinated against diphtheria under our campaign. Our volunteers are a tremendous support and they have brought 82,096 children to the government vaccination centers.
The strength of BRAC is that we work at scale maintaining quality with relevance and context. We believe in partnership. Along with strong partnership with the government of Bangladesh, UNs, NGOs, and community, we enhance and accelerate access of services to the disadvantaged and displaced populations who fled to Bangladesh physically and mentally devastated and traumatized. We continue to work with no one leaving behind.

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