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The world’s largest refugee camp prepares for COVID-19

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Nearly a million refugees live in overcrowded conditions in the camps of south Bangladesh. Gaia Vince reports on the growing fears of an imminent, catastrophic outbreak of covid-19

Gaia Vince science journalist and author
London, UK

Bangladesh, with its 168 million inhabitants, is one of the poorest and most densely populated countries in the world. Millions live cheek by jowl in slums, where 10 or more households share a toilet. People move around the country on packed buses, and still throng to markets and mosques. Last week, for instance, tens of thousands gathered in a field to pray for an end to covid-19.

On 26 March the government imposed a lockdown, including banning public transport, in a bid to combat the growing pandemic, although hundreds of workers have been crowding onto private vehicles, such as trucks, instead. Bangladesh has seen the number of confirmed cases of covid-19 rise above 39, with four known deaths. The south Asian nation responded earlier in March by banning flights, shutting down schools, and promoting hygiene and social distancing measures. With very limited testing, however, and only in the capital, Dhaka, the true number of cases is expected to be far higher, and the low income nation’s capacity to treat critically ill patients is limited.

And there’s one further factor—the overcrowded conditions of the world’s biggest refugee camp, located in Cox’s Bazar in the far south east of Bangladesh.

The second poorest district in the country, Cox’s Bazar is home to over 855 000 Rohingya refugees from neighbouring Myanmar (former Burma), as well as visiting aid workers.1 The refugees are survivors of a massacre, carried out by Myanmar’s military, of the country’s minority Muslim population. The refugees live on a hastily deforested hillside, with families, densely packed, sleeping on mats in one room shacks made from plastic woven walls and roofed with plastic sheets. The enormous, crowded “city” of shacks, that stretches as far as the eye can see, is served by few latrines and freshwater standpipes, and consequently many of the pathways run thick with sewage.

Maintaining basic hygiene is hard enough but striving for the increased coronavirus protection measures recommended by WHO seems Herculean. And yet, that’s what’s being attempted.

The United Nations High Commission for Refugees (UNHCR) is helping to coordinate efforts to increase hand washing at the site. “We’ve been working with partners for the past two weeks to install portable hand washing facilities at every community centre throughout the camps. We’ve made a good start, but this is ongoing,” Louise Donovan of UNHCR, who is based in Cox’s Bazar, told The BMJ.

“We’re also developing a managed roll-out of information in the three languages spoken in the camp—Rohingya, Bengali, and Chittagonian—to communicate WHO public guidance on handwashing frequently and thoroughly with soap and water, protecting coughs with an elbow, sneezing into a tissue, and so on,” she added. Aid workers are training trainers to take these messages throughout the camps, using community leaders, such as imams and women’s group leaders, to deliver the advice in a trusted way.

“People are generally apprehensive and worried about the virus,” Donovan said. “This is true everywhere in the country but particularly in the camps. Rumours spread easily.”

The aid workers have built up invaluable experience in communicating health advice and dealing with disease outbreaks over the past two and a half years, including the outbreaks of mosquitoborne infections such as malaria and dengue that occur with monsoons, and incidents of highly contagious bacterial infections, such as diphtheria and cholera. As a result, Donovan says, agency workers are generally seen as a credible, trustworthy source when people reach out for accurate information. “It’s amazing to watch the self-mobilisation of people helping to spread the messages through social media.”

Handwashing measures can only go so far to reduce spread of the virus once it enters the camp, though. Physical distancing, while an effective intervention elsewhere in the world, seems impossible in such crowded living conditions. Nevertheless, gatherings are being discouraged.

On 16 March, the Bangladesh government closed all schools, including the camp’s learning centres and community centres. This is a particular blow because the camp’s children have been denied any formal education because of government restrictions—these were to be lifted in April, allowing 10 000 children aged 11-13 access to schooling for the first time.