Better Health For All

On 13 February 2019 I visited Balukhali refugee camp (Camp 18 in the Kutupalong refugee camp) near Ukhia, a sub-district of Cox’s Bazar in South East Bangladesh. I travelled with my colleagues Dr Sam Watson and Ryan Rego as the guests of Drs Sirajul Islam and Mohammed Yunus from the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). Our purpose was to set up a study to test the utility of stool pathogen screening, rather than diarrhoea rates, as an outcome of choice in the study of Water, Sanitation and Hygiene (WASH) interventions. 

I had watched and read news reports about the plight of displaced Rohingya people, and as I travelled towards the camp I imagined that I would encounter a scene of squalor and desolation, reminiscent of the most extreme among informal urban settlements. 

What I found was completely different to my mental image. We drove into the camp along a pristine brick road. Dwellings were mostly made of bamboo, and were nicely laid out as in a French campsite. There were regular bore-hole outlets providing safe water at source, numerous advanced pit latrines, and no unpleasant smells. Many of the adult inhabitants were hard at work making a concrete drainage system in preparation for the coming monsoon. Children were in school. They looked healthy and were well-groomed. There were football pitches and plants growing in the many parts of the camp. 

Four things seem to have come together: 

1. The government in Bangladesh, after some hesitation, decided to accommodate the refugees – a country of 170 million can absorb another 1 million, said the Prime Minister. 
2. UN agencies, such as the High Commission on Refugees, were available to supply logistics and know-how. 
3. Money was provided on the back of the many NGOs that gravitated to the area. At the peak, over 150 NGOs had a presence in the camp. 
4. The effort was co-ordinated by the Office of Co-Ordination of Humanitarian Affairs. There was no ‘free-for-all’. 

Too good to be true? Yes, I am afraid so. If you look at “Open Street Map” (OSM) you will see that we visited a well laid out, orderly part of Ukhia. There is another section where the dwellings are much more closely packed among narrow lanes laid out in a disorderly way – much like a slum. Apparently, this was where the Rohingya settled following the initial, unanticipated influx that we all watched on our television screens. What lessons can I draw, tentatively, from my visit? 

First, what I observed is a good news story on balance – a tiny proportion of the worlds resources were harnessed and focussed on a real and present need, and the majority of the camps in Ukhia appeared to be in good order.  

Second, it is amazing what moderate resources can achieve, given an organising hand. I think there may be an important lesson in the contrast between the orderly, planned part of the Ukhia, and the disorderly sector where I understand WASH is less developed and intrinsic violence is prevalent. I hypothesise that planning for an influx of people lends itself to a favourable environment, whereas, once an urban area has developed in a disorderly way, it is much harder to remedy. 

Third, service provision in slums could learn a lot from refugee camps. Bamboo could be provided free of charge by NGOs to provide better insulated, more attractive accommodation. I fancy this would be a big improvement over corrugated iron shanties that are hot by day and freezing by night. Advanced pit latrines I observed in the camp would be a big advantage over the facilities usually provided in slums and their marginal cost is modest. Above all, a centrally co-ordinated approach is essential. I think cities that harbour slums should appoint officials with responsibility for informal settlements and a responsibility to co-ordinate investments and community engagement. 

Fourth, the problem for the Rohingya people is averted not solved – a long-term, sustainable solution is required and a return to Myanmar does not seem to be that solution. 

Written by Richard Lilford, Professor of Public Health at the University of Warwick. You can follow Richard on Twitter @rjlilford.