Creation in the Chaos: Developing Programs during the Disaster Response to the Rohingya Crisis in Bangladesh (A Case Study)
Background and Political Context
Being labeled as “a textbook example of ethnic cleansing” by the United Nations High Commissioner for Human Rights (Beyrer and Kamarulzaman, 1570), the Rohingya conflict in Myanmar has led to a fast growing refugee crisis in Bangladesh. The Rohingya, an ethnic and religious minority located largely in Myanmar, have faced ongoing persecution for decades. In 1982, Myanmar created the Myanmar Citizenship Law, which excluded the Rohingya from citizenship in the country, leaving them a stateless people (Brinham, 40).
On August 25, 2017, violence broke out with a military crackdown on the Rohingya, causing them to flee en masse to Bangladesh. Since August, approximately 838,000 Rohingya have crossed into Bangladesh and settled in refugee camps, adding to the approximately 212,000 Rohingya refugees who had already trickled across the border over the past 20 years (“Operational Update”). According to Médecins Sans Frontières, also known as Doctors Without Borders, at least 6,700 people were killed by the Myanmar military at the beginning of the 2017 refugee crisis (Beech).
Each humanitarian crisis has its own context, and the Rohingya refugee crisis has plenty of its own nuances. To start with, the refugee camp is a major place of international political battle. Myanmar has always considered the Rohingya to be illegal immigrants from Bangladesh, denying them citizenship. Yet Bangladesh doesn’t want them, either. The relatively smaller numbers from the past 20 years were more or less tolerated by the Bangladeshi government, but the influx of an additional 800,000 people has strained resources.
The Bangladeshi government has refused to acknowledge the refugee status of the Rohingya. They do not consider them to be refugees, opting instead to call them “forcefully displaced Myanmar nationals.” This is not without reason; by international law, using the term “refugee” obligates a host country to give refugees some essential rights and allow for humanitarian assistance. Calling them forcefully displaced Myanmar nationals is a strategy to halt such efforts. One such impact is that the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) has not been allowed into the country to respond. OCHA’s main role is coordination of humanitarian efforts. With OCHA’s presence missing, the response has been more disorganized, especially across sectors.
The government has tried a delicate balance of appearing to be cooperative with aid agencies while simultaneously making it difficult for them to fully operate. For example, the government has declared that only certain types of NGO-related visas will grant access to the refugee camps. However, as NGOs apply to receive status to request these visas for their aid workers, they are denied such status, forcing NGOs to operate on a technically illegal tourist visa. This puts them in a risky situation of being forced to stop services at any moment.
Bangladesh is now using language indicating that they believe the crisis is resolved and over with, as though the Rohingya are going to start heading home now. The reality is that the Rohingya aren’t going anywhere: Myanmar has placed landmines at the border, and is actively working on turning former Rohingya villages into military zones. But the impact will be felt: if Bangladesh says there is no longer a crisis, they may choose to shut down foreign aid work in the camps.
Lastly, the host communities have also started to build resentment toward the refugee camps. The influx of people means a spike in market prices for food and other goods. There is also resentment toward NGOs, who are seen as bringing in foreigners to fill job positions instead of giving them to community members. The neighboring town of Ukhia has had raised hostility toward international NGOs, accusing them of sucking the community dry and contributing nothing to them.
Creating a Program in the Midst of the Chaotic Context
All of these political and cultural complexities leads to the need for creative implementation of programs that are typically run with standardized approaches in the humanitarian field. There are several clusters included in a humanitarian response, all bound to standardized approaches through the Sphere guidelines: Shelter, WASH, food security, nutrition, education, health, logistics, early recovery, camp coordination and management, and protection. This standardization is based on decades of research and evaluation, allowing for the most impactful and cost effective programs to run. But standardization also serves another purpose: being able to plan a rapid response.
Without the need to develop new protocols and procedures every time, donors such as the World Food Programme, UNICEF, and in a refugee crisis, UNHCR, can work quickly on partnering with NGOs to carry out work across various sectors. One such sector is nutrition. In this paper, I will address three main areas of standardized nutrition approaches, how the unique context impacts the ability of standardized approaches to work well for the community, and the ingenuity in redesigning such approaches to be more effective. These nutrition components are promoting access to malnutrition services, infant and young child feeding in emergencies (IYCFE) nutrition counseling, and household education on nutrition.
Access to Malnutrition Services
In nutrition in disasters, one of the biggest areas of focus is malnourishment in children under the age of 5. There are a couple types of feeding programs that are set up to address cases of malnourishment in disasters, depending on the severity of malnourishment. Typically these programs run simultaneously. Cases of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) are sent to a site where children receive extra food rations and their weight gain is monitored.
In MTI’s programs, there are two points of contact with feeding programs in the camp: referrals through the clinic and referrals through community health workers. Feedback from households showed issues in the referral process. Households reported being turned away from nutrition sites, expressing frustration that these services didn’t work. But it proved difficult to have them continue to pursue services for their malnourished children because of two contextual factors: distrust for authority and fatalism.
The government’s feet dragging on fully cooperating with humanitarian assistance has led to disorganization in the response, namely due to the lack of OCHA’s presence. On the ground, this disorganization means that it is difficult to navigate which services are available to people within the camps and how they can access them. But from the context of the Rohingya, this is nothing new. They have learned to distrust authority because of the intense oppression and persecution they have faced within Myanmar. They have routinely been denied basic services, sometimes accessing them only as a fluke. To come into a camp and to be uncertain of where and how to access services is business as usual for the Rohingya. Having had little to no rights in Myanmar, there is little anticipation that they would have rights of access to services in the camp setting as well. These sentiments of distrust or even apathy are only compounded when NGOs on the ground give Rohingya households unreliable information, since coordination has proven difficult. To the Rohingya, NGOs lose credibility and trust, and continue to build a learned sense that there is nowhere to go to actually receive the help that is needed.
The inconsistency in services, coupled with the religious context, leads to a heavily fatalistic worldview among the Rohingya. Insha’Allah, or “Allah willing” is a common utterance for Muslims all across the globe. As about 90% of the Rohingya are Muslim, it is a common occurrence for “Insha’Allah” to be the perspective on malnourished children. If a child fails to thrive and dies of malnourishment, it is because God willed it to be so. If a nutrition site turns a family away—usually do to being in the wrong catchment area or not qualifying to be in that particular program—it is because God wills it to be so. This doesn’t make families any less concerned about the health of their children, but rather more accepting of the barriers to access, and ultimately, sometimes the suffering or even death of their children.
The lack of consistent and accurate information in the camp about malnutrition services undermined the credibility of both clinicians and community health workers (CHWs) when they referred households for services. My task was to go through the painstaking process of physically visiting each site to ask about catchment areas, admission and discharge criteria, and their own referral processes. Through this process we learned what is really happening when families are getting “turned away,” such as being misdiagnosed with malnutrition, or needing to be referred to a secondary site, or even managing household expectations of what types of services they will receive—namely, that malnutrition is treated with food, not with medicine, as many households were disappointed that they did not get medicine to take home. Understanding the link between the households and nutrition sites was a crucial part in making sure that children didn’t slip through the cracks. Clinicians as well as CHWs were trained in managing household expectations, explaining the process of getting enrolled, and minimizing the risk of sending them to the wrong nutrition site. Instead of relying on what is normally a fairly smooth process, I had to get inventive on collecting our own data on services. Through these means, fatalism leans more toward the positive: children are more likely to receive services, Insh’Allah—because that is God’s will for them.
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IYCFE Counseling Services
Another standard approach in emergencies is the emphasis on infant and young child feeding (IYCFE). As children under the age of 2 are more at risk for stunting and wasting, two of the most common forms of malnutrition, an added emphasis is placed on education of mothers and care takers, in particular on breastfeeding practices. For IYCFE counseling, shelters called “Mother Baby Areas” are routinely set up, staffed with nutrition counselors, so that women can address any issues they have with breastfeeding. In the Rohingya context, however, these counseling centers remain largely underutilized.
The conservative nature of the Rohingya also poses a unique context for work in the camp. Because of household duties such as cooking, cleaning, and caring for children, along with the need to receive permission from the head of household (typically the husband) to leave the house, women have greater difficulty in accessing services. Breastfeeding counseling is often seen as a low priority, and it is difficult for women to receive permission to leave the house for such services. Although the information given during counseling is still relevant to their context, the program itself becomes irrelevant due to restricted access.
Since women have difficulty leaving the home, it makes more sense for a nutrition counselor to come to them. Community health worker programs are widely utilized in both disaster response and community development, and community health workers (CHWs) are openly accepted into households across the camp. In MTI’s program, CHWs perform a brief nutrition education component, followed by asking if a mother would like to receive additional help with child feeding. If she would like the assistance, a nutrition counselor follows up with her in the privacy of her own home, negating the difficulties of gaining permission to leave the home.
Household Education on Nutrition
A third major piece of creating a relevant nutrition program was addressing the most pressing issue that was heavily related to childhood malnutrition: the use of breastmilk substitutes. In a disaster response, breastmilk substitutes are not allowed to be distributed, as they are frequently reconstituted with contaminated water, have a risk of being too diluted, and replace breastmilk, the most important food for an infant under 6 months. Like with many disasters, there are new NGOs that enter the field, unaware of the Sphere guidelines or the codes they need to follow. Powdered milk and infant formula are sometimes donated by private donors, and naïve NGOs freely distribute them. In return, they end up being reported and the BMS is confiscated. But by that time, it is often too late: packages of BMS have entered households and women stop breastfeeding. Or, they get sold in markets, spreading the use of BMS even wider.
It is quite common in the camp for women to give up exclusively breastfeeding and switch to formula. Standard IYCFE education emphasizes the importance of exclusive breastfeeding and the risks of using BMS, but for as large as a problem as it is in the camp, it needs to be even more emphasized than in standard training for CHWs and nutrition counselors. Furthermore, the material for IYCFE education must be contextualized to include the most common difficulties that women in the camp face with breastfeeding as well as address the common reasons why women stop breastfeeding. The aim is to arm community health workers and nutrition counselors with material that will answer the questions they are faced with in the household, solving real world problems that Rohingya mothers relate to.
Disaster response goes hand-in-hand with disaster preparedness, but as much as the humanitarian field is prepared to respond, the field is always rapidly evolving both in terms of standards and in terms of contextual considerations. Humanitarian aid agencies need to be prepared to rapidly but accurately assess the situation and to roll out plans that consider the context so that they are more effective in their implementation. There is a need to create the room—and allow for the inventiveness—to think outside of the box in order to fulfill the mission of the United Nations High Commission on Refugees: “To safeguard the rights and the well-being of refugees” (“UNHCR Mission Statement”).
Beech, Hannah. “At Least 6,700 Rohingya Died in Myanmar Crackdown, Aid Group Says.” The New York Times, The New York Times, 14 Dec. 2017, http://www.nytimes.com/2017/12/14/world/asia/myanmar-rohingya-deaths.html.
Beyrer, Chris, and Adeeba Kamarulzaman. “Ethnic cleansing in Myanmar: the Rohingya crisis and human rights.” The Lancet, vol. 390, no. 10102, 30 Sept. 2017, pp. 1570–1573., doi:10.1016/s0140-6736(17)32519-9.
Brinham, Natalie. “The Conveniently Forgotten Human Rights of the Rohingya.” Forced Migration Review, vol. 41, no. 41, 2012, pp. 40–41.
“Operational Update.” UNHCR, 9 Feb. 2018, data2.unhcr.org/en/documents/download/61917.
UNHCR Mission Statement, UN High Commission on Refugees, unhcr.org.ua/en/contact-us/basic-facts/27-basicfAact.
Fulcrum Missions 