Karsten Noko is the Head of Mission for Médecins Sans Frontières (MSF) projects in Cox's Bazar, Bangladesh. He began his career with MSF, widely known as Doctors Without Borders, in his home country of Zimbabwe in 2009. He has also worked in a number of other countries in Africa and Asia, where he has been involved in providing humanitarian assistance and medical care to displaced populations. In a recent interview with Dhaka Tribune Chief Reporter Ali Asif Shawon, he discussed some of the health issues at the world's largest refugee camps in Cox's Bazar.
Dhaka Tribune: Give us an overview of the current situation in Cox's Bazar and the Rohingya camps, and the specific challenges MSF faces in delivering health care and humanitarian assistance there.
Karsten Noko: Thank you for taking the time to have this conversation with us. So, at the moment, what we see in Cox's Bazaar is that in the provision of humanitarian assistance versus the needs—the medical and humanitarian needs that people have—there continues to be a growing gap.
Part of it is linked to the funding situation, and what we see is that, more and more for us as a medical organisation, we continue to see more people coming to our facilities seeking health care, coming from camps that are further from our health facilities.
Mehedi HasanWe continue to see outbreaks of diseases, and, in this particular instance, we can see an outbreak of scabies. It is very difficult for us to cope with the number of patients that we receive. We do not have the capacity, the manpower, or the physical space to continue to receive the number of people that we are receiving.
Recently, scabies has been a significant concern in Cox's Bazar, and I read your press release where you stated that the scenario is very alarming, with a 40-70% affected rate. It is very challenging to combat scabies in the densely populated Rohingya camps, so how are you going about handling the prevention, diagnosis, and treatment of scabies at Rohingya camps?
Yes, it is indeed true. In May, the health sector in Cox's Bazar conducted a survey and found that, on average, almost 40% of the population in the camps has scabies. In some of the camps, it is true that the rates go far higher, reaching up to 70%.
We started sounding the alarm bells back in March of 2022, when we made sure that we had a specific capacity to deal with the increasing number of scabies that we were seeing.
The challenges start at the shelter, as you rightly say, with the congestion in the camps. Water and sanitation facilities also continue to be a challenge, and this is what makes it difficult to contain the outbreak. It is not surprising at the end that the health facilities that are at the end of the chain get overwhelmed and are not able to cope with the number of patients. But the problem is a systematic one, and the health facility is basically the end of the chain, where you see the magnitude of the problem.
Do you think the recent Rohingya aid cut could impact the recent scabies outbreak and some other diseases in the Rohingya camps?
It is true that for people who are today almost completely reliant on humanitarian assistance, we have seen a worrying reduction in funding throughout, particularly in the year 2023.
We are concerned that this will have an impact on health needs, because it means that the fewer health facilities that remain have to cope with an increasing number of patients, but also because the funding reduction has health consequences because if people are not able to get enough food or enough soap, it means that even practising hygiene becomes more and more difficult.
So, we expect that with the reduction in funding, we will continue to see an increase in unmet humanitarian needs, making the situation even more precarious than it is today.
Olivier MalvoisinSo now, what are your thoughts about reducing the number of scabies patients? Are you thinking of a mass evacuation or something similar?
The UN health sector is going ahead with proposals to conduct a mass drug administration, which allows the people in the camps who are all at risk of getting scabies to get medication to hopefully prevent and control the outbreak.
We are also aware of the fact that, with the current conditions of the camps, with the current water and sanitation facilities, the current congestion, the current shelters that people live in where they have to share sleeping mats and all of these things, the measures that we know on how to control the scabies cannot work in the kind of setting that we are in. Discussions about a mass drug administration continue to develop, but other sectors should also contribute.
For example, one of the ways to control the outbreak is for people to boil their clothes in hot water, at 60 degrees, for some time to kill the mites that cause scabies. But with the reduction in the LPG gas that people have available, even those measures are not viable for them. So, we continue to see all of these challenges, and it points to the fact that without a coordinated, multi-pronged approach, there is a very big risk that the mass drug administration will not get the kind of results that we are hoping that it will get.
Have you conducted a coordinated approach with other actors? If so, what feedback are you getting from them?
Since 2022, we have been engaging with them, talking to them, and asking them to also ensure that they have capacity. They have the drugs to cope with the increasing number of patients. We have engaged with organisations working within the water and sanitation sectors.
So, all of these are long-standing discussions that we have been having. In terms of feedback, everyone at the moment, what the survey did back at the end of May, when we got the results, basically confirmed how big the problem was.
So, at the moment, we are waiting for the people within the leadership of the health sector coordinator, to work on making sure that there are enough drugs to ensure a mass drug administration.
We are talking about over a million people in the camp, so it's a lot of people. And so, there's a lot of logistics work involved.
At the end of the day, based on the feedback that we get from the actors, everyone is willing to put solutions on the table. But at the end of the day, from the ideas to the practical implementation, that is where we need to see more and more effort being made and plans being developed, not just acknowledging that there's a problem.
When should mass drug administration start?
The mass drug administration will be conducted by the health sector. They are professionals, they have the technical skills that are needed, so we wait for their leadership. So, we wait for them to tell us how the plan will roll out, and we continue to give the support that we can.
What is clear is that the mass drug administration has to be done as soon as possible, because otherwise the problem will continue to fester, and we will continue to have more and more patients that we are not able to provide care to.
How many patients are you dealing with on a daily basis?
We are seeing on average between 600 and 700 patients every day for scabies alone in camps 14 and 15. This is only for two of the camps. On many days, we also reach the capacity of the patients that we can treat, and so we have to redirect patients and ask them to go to other health facilities, because the medical personnel cannot see more people after a certain number of consultations . They also get tired, and we don't want them to be too tired and start making mistakes.
Could you highlight some of the most significant achievements or milestones that MSF has accomplished in Cox's Bazar? What are the key factors contributing to this success?
Olivier MalvoisinMSF has been working in Bangladesh since 1972, so we have a long history of working in the country. We have been working and trying to respond to various emergencies over the years.
In Cox's Bazar itself, it's difficult to talk about achievements today because of the sheer medical needs that we see. For us, achievements would be having a health system that is able to cater to the needs of the population, and we're talking about increasing needs, as the situation clearly has become chronic. Other medical issues also develop, from non-communicable diseases to other complicated medical issues. I think, for me, the biggest achievement that we can have would be to see all health actors working together to address issues. MSF, of course, is willing and ready to continue to contribute to those efforts.
Can you share an example of a difficult situation that you have faced recently in the Rohingya camps in an emergency situation?
Recently, I would probably think of cyclone Mokha that was affecting, or at least that was anticipated back in May, even though in the end it did not come directly to the camps as had been feared.
For this particular situation, it involved the fact that, as the cyclone was coming, we had to evacuate our medical facilities, some of them, not all of them, but most of them, because the kind of material that we used for construction could not withstand the 215 kilometres per hour wind that was expected.
So, we had to evacuate our facilities, but not just that, we also had to be ready to redeploy once that was over, because we would expect that that is when we would be most needed.
Within a period of two or three hours, we were back again and receiving patients, which was quite important for us, even though the cyclone did not hit the way that it was expected.
But yes, emergency preparedness is a core part of what we do as MSF, being ready to respond, and being the first responders whenever something happens.
Let's turn to some of the key health issues and medical needs that you are prioritising in Cox's Bazar. How has MSF addressed these needs while considering cultural sensitivity and community engagement?
Answer: MSF today works in about 70 countries, serving many different communities with many different social systems. Over time, we have developed the capacity to engage with communities, engage with leaders, and engage with groups of communities, including what we would consider to be the most vulnerable in certain situations.
We always want to make sure that our medical services are adapted to the people that we seek to provide care to.
In Cox's Bazar, people are coming to us with all kinds of health needs, not just scabies. This includes women coming to deliver in our facilities, some with non-communicable diseases. So, today we have quite a rich array, I would say, of services that we offer.
It is still not enough, unfortunately, and what we are worried about is that, as the funding reduces, some of these health facilities around us will close, and that we will have to do more, even though we are not able to anymore because we have reached the limit of what we can do.
