Dealing with the challenges of extreme population density

I’m based in Cox's Bazar and I regularly go to Ukhiya, which is the subdistrict of Cox’s Bazar where the refugee camps are located.

There are 25 refugee camps in the area and the mission I’m working on covers 3 of them, which are home to 100,000 people. Just think – in total, these 25 refugee camps represent around 1 million people. They are genuinely immense, and extremely densely populated: the people there are literally living on top of each other. This high concentration of people makes for a lot of work, but we have managed to set up a good level of primary healthcare. The need for this here is so high that we actually have four MSF teams on the ground, each of which is working on different projects. I am the medical coordinator for one of these teams.

In terms of the hospitals, emergency surgery is something that we’ve had a few issues with as one of the hospitals which used to be supported by another NGO has closed, so the other hospitals have had to restructure. The referral and rotation system is not yet fully sorted, and sometimes you really have to insist on some urgent cases – emergency C-sections, for example – being referred. This is down to a lack of qualified human resources, such as gynaecologists.

When populations are highly concentrated, the risk of an epidemic spreading is high. Here, the highest risk is cholera. People have been repeatedly vaccinated in an attempt to manage this risk, and we are hoping to avoid a cholera epidemic. 

We are currently dealing with a chicken pox outbreak, which really affects teenagers and adults. Normally chicken pox isn’t a serious illness except for vulnerable people such as pregnant women, and our teams have not yet had to handle any complicated cases.

We've got three health centres for outpatient consultations and reproductive healthcare, including family planning, pre- and post-natal health and delivery facilities.

MSF also organises activities to promote health within the community – particularly focusing on hygiene – and mental healthcare, providing psychological and psychiatric support to people living with mental conditions.

There is also a WatSan (Water and Sanitation) element to this project, which focuses on access to water and toilet facilities: three wells provide the population with drinking water, and MSF is building toilet facilities.

In Cox’s Bazar specifically, MSF is supporting a Ministry of Health hospital with hospital hygiene and waste management by upgrading waste areas and providing hygiene training to hospital staff.

That really depends on the political situation. Talks were held in November about repatriating refugees, but it looks like the situation in Myanmar is far from optimal for these people. The elections in Bangladesh have been a hot topic over the past few weeks, and the issue of the refugees has taken a back seat.
We can see that refugees are still arriving, populations are still migrating, and that the situation is not stable and unlikely to improve over the coming months. Recently, most of the people arriving here are from India.

Healthcare is working well, but the population is extremely dense and there are many humanitarian actors.

This is the first time that I’ve worked as a medical coordinator on an established mission, but I have been one in emergency situations before.

I regularly go to the Cox’s Bazar hospital to supervise activities there. I also frequently visit the various refugee camps, and I’m currently filling the role of camp medical manager while it’s empty: I recently spent three weeks in the field, where I had much more contact with our patients.

In terms of specific challenges, all you need to do is think about how huge it all is, and how many actors there are (the Bangladeshi Ministry of Health, other local ministries, the United Nations and dozens of international and local NGOs are also involved). Communication can be tricky, especially where medical information is involved: we can’t just casually pass on the same data to lots of different actors when some of them don’t communicate with each other! Lots of actors means lots of work. We pass information on to the Ministry of Health and district-level organisations. Coordinating the communication of information and reaching mutual agreements can get complicated!

The density of the population is also a challenge. There are 100,000 people in the camp where my team works, and there are no sewage pipes like we have in Europe: when the toilets are full, they need to be emptied. There’s no central disposal unit for waste management, and routes through the camp are hardly large enough for a bicycle to get through, so a truck would be impossible! This is a logistical challenge too, as there is no public system for disposing of rubbish: MSF must manage the waste produced in its health centres. For example, we give patients bottles of water for ORS (Oral Rehydration Solutions), so we need to work out how to replace these bottles and facilitate the logistics that requires (waste and plastic management).

I split my time between our mission’s coordination office and field visits to hospitals and health centres.

I start at 07:00 in the morning. I come to the office and make the most of the quiet time to check my various inboxes.

Next, I have what we call “cluster meetings” once or twice a week with the other NGOs and UN representatives to coordinate our activities.

I also need to get responses to my teams, who ask me for advice on which protocols to use. With the chicken pox, for example, I contacted headquarters for their recommendations, and we decided to vaccinate our staff against chicken pox. There’s a lot of administration and coordination between headquarters and other stakeholders. When I’m out in the field, I try to visit the health centres where medical meetings are taking place before I go and see what’s happening with health centre activities.

As a rule, I tend to head back to the office at around 16:00. But I don’t really have a “standard day”.

Seeing the challenges that face us and how there is always something to sort out is really motivational! You realise that MSF is making a real impact. If you look at the number of consultations carried out each month, it’s really something!

For example, we had to close one of our three maternity units in August because the midwives working for MSF went to work for the Ministry of Health. We weren't in a position to deliver any babies, so we had to organise a recruitment drive and training: we started deliveries in health centres again two months ago. We are having a positive impact as women have been having their babies at home whilst maternity clinics haven’t been available, along with all the risks that entails.

When you see how all this positive impact adds up, that’s huge inspiration to carry on working.

Yes – our Bangladeshi logistics supervisor took his wife to the public hospital about a week ago, and said that it was much cleaner than it was six months ago. That shows the impact our work is having: how cleaning, hospital hygiene and waste management have improved. He was proud to say that he works for MSF.

Thank you so much – it’s so kind of you to send me these encouraging messages. It’s great to see that people are interested, and it is really motivating – both for me and my team – to see that people are thinking of us.

If anyone out there with a background in nursing, logistics or finance wants to become an expat then you’d be very welcome here!