Mortality in Rohingya refugee camps in Bangladesh: historical, social, and political context

Fifty-two maternal deaths occurred between September 2017 and August 2018 in the Rohingya refugee camps in Ukhia and Teknaf Upazilas, Cox\u27s Bazar District, Bangladesh. Behind every one of these lives lost is a complex narrative of historical, social, and political forces, which provide an important context for reproductive health programming in Rohingya camps. Rohingya women and girls have experienced human rights violations in Myanmar for decades, including government-sponsored sexual violence and population control efforts. An extension of nationalist, anti-Rohingya policies, the attacks of 2017 resulted in the rape and murder of an unknown number of women. The socio-cultural context among Rohingya and Bangladeshi host communities limits provision of reproductive health services in the refugee camps, as does a lack of legal status and continued restrictions on movement. In this review, the historical, political, and social contexts have been overlaid below on the Three Delays Model, a conceptual framework used to understand the determinants of maternal mortality. Attempts to improve maternal mortality among Rohingya women and girls in the refugee camps in Bangladesh should take into account these complex historical, social and political factors in order to reduce maternal mortality

Optimizing the Use of a Precious Resource: The Role of Emergency Physicians in a Humanitarian Crisis

Emergency physicians (EP) are uniquely suited to provide care in crises as a result of their broad training, ability to work quickly and effectively in high-pressure, austere settings, and their inherent flexibility. While emergency medicine training is helpful to support the needs of crisis-affected and displaced populations, it is not in itself sufficient. In this article we review what an EP should carefully consider prior to deployment

Documentation of human rights abuses among Rohingya refugees from Myanmar

Background: Decades of persecution culminated in a statewide campaign of organized, systematic, and violent eviction of the Rohingya people by the Myanmar government beginning in August 2017. These attacks included the burning of homes and farms, beatings, shootings, sexual violence, summary executions, burying the dead in mass graves, and other atrocities. The Myanmar government has denied any responsibility. To document evidence of reported atrocities and identify patterns, we interviewed survivors, documented physical injuries, and assessed for consistency in their reports. Methods: We use purposive and snowball sampling to identify survivors residing in refugee camps in Bangladesh. Interviews and examinations were conducted by trained investigators with the assistance of interpreters based on the Istanbul Protocol - the international standard to investigate and document instances of torture and other cruel, inhuman, and degrading treatment. The goal was to assess whether the clinical findings corroborate survivors\u27 narratives and to identify emblematic patterns. Results: During four separate field visits between December 2017 and July 2018, we interviewed and where relevant, conducted physical examinations on a total of 114 refugees. The participants came from 36 villages in Northern Rakhine state; 36 (32%) were female, 26 (23%) were children. Testimonies described several patterns in the violence prior to their flight, including the organization of the attacks, the involvement of non-Rohingya civilians, the targeted and purposeful destruction of homes and eviction of Rohingya residents, and the denial of medical care. Physical findings included injuries from gunshots, blunt trauma, penetrating trauma such as slashings and mutilations, burns, and explosives and from sexual and gender-based violence. Conclusions: While each survivor\u27s experience was unique, similarities in the types and organization of attacks support allegations of a systematic, widespread, and premeditated campaign of forced displacement and violence. Physical findings were consistent with survivors\u27 narratives of violence and brutality. These findings warrant accountability for the Myanmar military per the Rome Statute of the International Criminal Court (ICC), which has jurisdiction to try individuals for serious international crimes, including crimes against humanity and genocide. Legal accountability for these crimes should be pursued along with medical and psychological care and rehabilitation to address the ongoing effects of violence, discrimination, and displacement

Poder, política y privilegio: la salud pública en la frontera de Tailandia y Birmania

Los participantes de un curso de métodos de investigación de campo sobre la salud de los refugiados en la frontera de Tailandia y Birmania aprendieron que más allá de los vectores biológicos y de los procesos de las enfermedades que contribuyen al sufrimiento humano, el poder, la política y el privilegio juegan papeles centrales que afectan de forma negativa a la salud de los refugiados

Health and human rights in eastern Myanmar prior to political transition: a population-based assessment using multistaged household cluster sampling

Background: Myanmar/Burma has received increased development and humanitarian assistance since the election in November 2010. Monitoring the impact of foreign assistance and economic development on health and human rights requires knowledge of pre-election conditions. Methods: From October 2008-January 2009, community-based organizations conducted household surveys using three-stage cluster sampling in Shan, Kayin, Bago, Kayah, Mon and Tanintharyi areas of Myanmar. Data was collected from 5,592 heads of household on household demographics, reproductive health, diarrhea, births, deaths, malaria, and acute malnutrition of children 6–59 months and women aged 15–49 years. A human rights focused survey module evaluated human rights violations (HRVs) experienced by household members during the previous year. Results: Estimated infant and under-five rates were 77 (95% CI 56 to 98) and 139 (95% CI 107 to 171) deaths per 1,000 live births; and the crude mortality rate was 13 (95% CI 11 to 15) deaths per thousand persons. The leading respondent-reported cause of death was malaria, followed by acute respiratory infection and diarrhea, causing 21.2% (95% CI 16.5 to 25.8), 16.6% (95% CI 11.8 to 21.4), and 12.3% (95% CI 8.7 to 15.8), respectively. Over a third of households suffered at least one human rights violation in the preceding year (36.2%; 30.7 to 41.7). Household exposure to forced labor increased risk of death among infants (rate ratio (RR) = 2.2; 95% CI 1.1 to 4.4) and children under five (RR = 2.1; 95% CI 1.3 to 3.6). The proportion of children suffering from moderate to severe acute malnutrition was higher among households that were displaced (prevalence ratio (PR) = 3.3; 95% CI 1.9 to 5.6). Conclusions: Prior to the 2010 election, populations of eastern Myanmar experienced high rates of disease and death and high rates of HRVs. These population-based data provide a baseline that can be used to monitor national and international efforts to improve the health and human rights situation in the region

Integrating community health volunteers into non-communicable disease management among Syrian refugees in Jordan: a causal loop analysis.

OBJECTIVES: Globally, there is emerging evidence on the use of community health workers and volunteers in low-income and middle-income settings for the management of non-communicable diseases (NCDs), provision of out-of-clinic screening, linkage with health services, promotion of adherence, and counselling on lifestyle and dietary changes. Little guidance exists on the role of this workforce in supporting NCD care for refugees who lack access to continuous care in their host country. The goals of this work were to evaluate the current roles of community health volunteers (CHVs) in the management of diabetes and hypertension (HTN) among Syrian refugees and to suggest improvements to the current primary care model using community health strategies. SETTING AND PARTICIPANTS: A participatory, multistakeholder causal loop analysis workshop with representatives from the Ministry of Health of Jordan, non-governmental organisations, United Nations agencies, CHVs and refugee patients was conducted in June 2019 in Amman, Jordan. PRIMARY OUTCOME: This causal loop analysis workshop was used to collaboratively develop a causal loop diagram and CHV strategies designed to improve the health of Syrian refugees with diabetes and HTN living in Jordan. RESULTS: During the causal loop analysis workshop, participants collaboratively identified and mapped how CHVs might improve care among diagnosed patients. Possibilities identified included the following: providing psychosocial support and foundational education on their conditions, strengthening self-management of complications (eg, foot checks), and monitoring patients for adherence to medications and collection of basic health monitoring data. Elderly refugees with restricted mobility and/or uncontrolled disease were identified as a key population where CHVs could provide home-based blood glucose and blood pressure measurement and targeted health education to provide more precise monitoring. CONCLUSIONS: CHV programmes were cited as a key strategy to implement secondary prevention of morbidity and mortality among Syrian refugees, particularly those at high risk of decompensation

Rapidly adapted community health strategies to prevent treatment interruption and improve COVID-19 detection for Syrian refugees and the host population with hypertension and diabetes in Jordan.

BACKGROUND: We evaluated community health volunteer (CHV) strategies to prevent non-communicable disease (NCD) care disruption and promote coronavirus disease 2019 (COVID-19) detection among Syrian refugees and vulnerable Jordanians, as the pandemic started. METHODS: Alongside medication delivery, CHVs called patients monthly to assess stockouts and adherence, provide self-management and psychosocial support, and screen and refer for complications and COVID-19 testing. Cohort analysis was undertaken of stockouts, adherence, complications and suspected COVID-19. Multivariable models of disease control assessed predictors and non-inferiority of the strategy pre-/post-initiation. Cost-efficiency and patient/staff interviews assessed implementation. RESULTS: Overall, 1119 patients were monitored over 8 mo. The mean monthly proportion of stockouts was 4.9%. The monthly proportion non-adherent (past 5/30 d) remained below 5%; 204 (18.1%) patients had complications, with 63 requiring secondary care. Mean systolic blood pressure and random blood glucose remained stable. For hypertensive disease control, age 41-65 y (OR 0.46, 95% CI 0.2 to 0.78) and with diabetes (OR 0.73, 95% CI 0.54 to 0.98) had decreased odds, and with baseline control had increased odds (OR 3.08, 95% CI 2.31 to 4.13). Cumulative suspected COVID-19 incidence (2.3/1000 population) was suggestive of ongoing transmission. While cost-efficient (108 US${\$}$/patient/year), funding secondary care was challenging. CONCLUSIONS: During multiple crises, CHVs prevented care disruption and reinforced COVID-19 detection

Health and Human Rights in Chin State, Western Burma: A Population-Based Assessment Using Multistaged Household Cluster Sampling

Sollom and colleagues report the findings from a household survey study carried out in Western Burma; they report a high prevalence of human rights violations such as forced labor, food theft, forced displacement, beatings, and ethnic persecution