What will happen when COVID-19 hits refugee camps?
That's what Dr. Paul Spiegel and a team of researchers have been examining. They've been looking at how the coronavirus might affect the densely populated camps outside Cox's Bazar, Bangladesh — home to 850,000 Rohingya refugees from Myanmar. As of Monday, there are 49 cases in the country, including one person in the town of Cox's Bazar.
The researchers will use the findings to make recommendations to the United Nations and global aid groups on how to deliver medical care and check the spread of the coronavirus in similar refugee settings.
Spiegel, a former senior official at the U.N. High Commissioner for Refugees and the director of Johns Hopkins University's Center for Humanitarian Health, explains why these camps are ripe for disease outbreaks — and what aid groups must do now to help. This interview has been edited for length and clarity.
You've been working in humanitarian aid for over 20 years. Have you ever seen anything like this before?
No, this is unique, I must say.
Why did you decide to look at the camps near Cox's Bazar specifically?
They really are packed together with incredibly high density. And so when you think about disease transmission, this is sadly a perfect storm for COVID-19 to transmit.
Why is that?
It's a hilly and crowded place with lots of dwellings and huts, and people are living one on top of the other. In monsoon season and the flooding season that can be incredibly muddy and dirty and unsanitary.
You have communal latrines as opposed to individual latrines. They're often dirty and not well-kept. The other thing is that people who come to the camp are not in particularly good shape [due to poverty and malnutrition]. They have an overall poor health status and that is ripe for epidemics to occur.
And these camps have experienced disease outbreaks before.
There have been outbreaks of diphtheria and measles. So we already know that this is an area where outbreaks will occur.
What about the coronavirus?
This is something I don't want to envision too much, although I do think it's extremely likely that something will happen in this area.
Is it even possible to avoid transmission of disease in these settings, or is it inevitable?
The government of Bangladesh and the international community provided oral cholera vaccines to the refugees because they knew it was ripe for a massive cholera epidemic. And so far it has not happened, which is incredible.
It's a good example of prevention, but that is not going to be the case for coronavirus, obviously, because there is no vaccine.
If there is a coronavirus outbreak at Cox's Bazar, will patients be able to get medical care?
There are some basic hospitals at the camps, and there are approximately 300 beds or so that are available. But they will be quickly overwhelmed.
Of course, if there is an outbreak in that camp, it's likely there's going to be an outbreak in the surrounding areas as well. And governments [that host refugee camps] are going to have to decide who uses their facilities. Most would save their hospital beds and their intensive care units for their own citizens.
Can aid workers deploy some of the same coronavirus interventions as we've seen in other countries?
Those interventions are not likely to be doable. Not just in the Rohingya camps, but [in other refugee camps]. You cannot social distance from people in a place like this, where there are so many people in such a small, densely populated area.
In terms of intubation and being put on a ventilator [a treatment for severe cases of COVID-19], I have my doubts if that's going to happen in this situation or in many other situations. I don't think that refugees will have access to that in [the national hospitals of their host countries] if the nationals need it. I think that would be very hard for a government to agree to but I hope I am wrong.
What do aid workers need to provide care to places like Cox's Bazar at this moment in time?
A lot of protective gear, a lot more beds. They're going to have to train health care workers. They're going to need to figure out where to bury people.
What is the humanitarian community doing now to prepare?
There are some guidelines that are coming out at the global level from Geneva [where the U.N. is headquartered] and elsewhere. But guidelines at that level are nonspecific.
I've spoken now to at least six nongovernmental organizations and also some U.N. agencies to get an idea of what people are doing [on the ground]. In many situations, the recommendations are going to have to come from the affected populations.
What kinds of ideas have come out of those discussions?
In camps where schools have been closed [due to coronavirus], what do you do with that group of educated adults and teachers? How can we use them best? Do we use them for hygiene promotion or do we actually start teaching them how to treat mild cases of COVID-19 because the health care workers are going to be way too busy with more severe cases?
You have to think broadly in terms of what you can do. For example, you now have schools that are closed. Can we also use some of those schools as areas where we can isolate patients?
Any ideas that give you pause?
Some of the ideas may not be accepted by the population. For example, if we tell refugees that we are going to put all the elderly and people with chronic conditions in houses together so they can't get infected — which means they won't get to see their children — they may not accept that for cultural reasons.
So what will aid workers do?
They have to take a risk. Our No. 1 rule is to do no harm. But we have to do something. If we do nothing, the harm is going to be so extreme. There's no guarantee that if we [isolate those people] that it will make the situation better. It may make the situation worse. And that's a horrible thing to consider. But we're not in normal times.
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