Social distancing isn’t easy. But social distancing in the world’s largest refugee camp? Nearly impossible, says Deepmala Mahla, CARE’s Regional Director for Asia. In Cox’s Bazar, as many as 70,000 people live in the space of a single square kilometer, while the nearest COVID-19 testing facility is a 12-hour bus ride away.
As cases of the virus appear in Bangladesh and other densely populated areas throughout India and Asia, CARE is scaling up its response to reach those most vulnerable to the disease. In a conversation with CARE President and CEO Michelle Nunn, Mahla explains the dire implications of a COVID-19 outbreak in places like Cox’s Bazar and where she finds hope in CARE’s work.
Michelle Nunn: Can you give some perspective on where things stand in your region and the trajectory of the [coronavirus] impact?
Deepmala Mahla: We started grappling with the issue of coronavirus in early January. To be honest, this is unprecedented. None of us knew that it would become so big. As of now in Asia, the numbers are growing in terms of prospective cases, infected, and number of deaths. But, if we look at the country context here, the health systems are already overcrowded. We worry the actual numbers [of infected] are higher and the number [of reported cases] is smaller because of the [lack of] testing facilities. In Bangladesh, a country with slightly shy of 200 million people, there’s only one testing facility.
There are so many people in this region who only get their dinner or lunch when they go out to earn it that particular day.
Our worries are multifold: Firstly, not enough knowledge of how big the problem is; secondly, already weakened [health] systems; and thirdly, the migration patterns are very, very big and we have some of the biggest refugee camps, including Cox’s Bazar. We are [facing] the issue of stopping the spread [of coronavirus] where we are, and the medium to longer-term issues of loss of livelihoods. There are so many people in this region who only get their dinner or lunch when they go out to earn it that particular day.
MN: Deepmala, you spoke about the Rohingya settlement and there have been reports of a couple of cases there. Can you give us a picture of what the implications of that might be?
DM: [Cox’s Bazar] is the world’s largest refugee camp, which houses 855,000 people. How much is the space in which they are living? Picture this: On average, 40,000 people per square kilometer. And, there are places within the camp where it goes to 70,000 people per square kilometer. What sort of dwellings do these people live in? They’re flimsy shelters made of bamboo and thatch over a very low cemented platform. The entire family lives in one room and they share all water and hygiene facilities, like taps to collect their drinking water, handwashing points, latrines, which means not only are people using a single facility, they are overcrowded.
And let’s not forget why these people are here: They suffered immense, unspeakable trauma and violence.
Adding more complexity is that the terrain of these camps is not flat – it’s very uneven, hilly, and steep, which means mobility for the elderly, disabled, and pregnant women is difficult. And let’s not forget why these people are here: They suffered immense, unspeakable trauma and violence by the time they came to the camp, which means it’s a traumatized population that is mentally not at its strongest and their immune systems are lower. I cannot even imagine [social distancing] happening.
There has been one positive [coronavirus case in Cox’s Bazar], but the person is not inside the camps. The only testing facility in [Bangladesh] is in Dhaka – if you take a bus, it might take you 10 or 12 hours [from the camps]. I have been to a lot of camps, but when I think about a COVID-19 outbreak in Cox’s Bazar, I shudder to think what it could be in terms of the magnitude and the implications.
people live per square kilometer on average in Cox’s Bazar
MN: It’s hard to wrap your head around all the challenges you’ve just laid out. Sheltering in place is taking place all over India. As you think about these global capitals, can you explain what the challenge looks like in a place like India or Asia in terms of population density?
DM: 70-100 million people are on the road trying to reach where their homes are. Social distancing is a solution, so in a county like India, you do step-by-step lockdowns, but there are so many seasonal migrants who go to another state or province to earn their daily living. When there’s a lockdown, people aren’t getting their daily wages, which means they don’t have anything in terms of to eat, to stay, or to sleep. Buses, trains, and everything else has been stopped [by the government] and these people make the decision to walk to their homes [with no other option]. Just imagine the level of desperation when a family makes that decision to walk 100-250 kilometers. People have said, ‘We’re not afraid coronavirus will kill us, but starvation and so much walking will definitely kill us.’
When [government] measures are taken in big capitals, the challenge which agencies [like CARE] face is, how do we as humanitarians go to help those communities with a soap bar, or advice, or a helpline number? In addition to designing interventions which will help the people, getting the supplies and making useful things available to the people like water and soap, we also have to worry about how will we access those populations and adhere to the regulations of the host government?
MN: What are the gendered implications perhaps based on what’ve learned in the past with Ebola and analysis already taken place around COVID-19?
DM: [Gender] is the backbone of much of [CARE’s] work. In Cox’s Bazar, 80% of the people are women and girls so it is an absolute no-brainer that our interventions should be focused on women and girls. The household burden is shared more by women and girls, so when people are not able to go out, the burden on the family to earn a livelihood is bigger. Who sacrifices the meal first? Women and girls. That has a chain. When all this is happening, people still have reproductive health needs – women are still pregnant, and women are still delivering babies, so the prioritization of sexual and reproductive health becomes difficult. Whenever CARE is designing a response, we are concerting with the women and girls. There are youth groups with really vibrant girls, and however depressing the environment is, you talk to them for 15 minutes, you start feeling better. Many times, they give us advice on [where to put handwashing stations].
MN: Given all that, can you give us a piece of hope about what CARE is doing and can do moving forward?
DM: CARE has been in this region since before most of us were born, which means we know the system very well, we know the communities very well, we know our local NGO counterparts, and CARE is trusted. I go to many countries and people say they don’t know what’s happening, but they see the CARE logo on a Jeep and there’s a sense of comfort.
We’re starting our work by assessing what the communities need and what the gaps are. For instance, in Cox’s Bazar refugee camps, information is key. So, we have translated simple information for the community in posters, pamphlets, short videos, and radio messages. Most of CARE’s work is around bringing people together. We can’t do that anymore, so we’ve adapted by doing home visits and we are working with the Health Departments [to keep clinics safe] and decongest waiting areas.
Hope is definitely there, we just have to be patient. My worry is there is a lot of attention on [coronavirus] right now, but after some time we get used to it and we get empathy fatigue. If that happens in this crisis, it will be very detrimental because the livelihoods of many people have been affected.