Reflections from the Rohingya Refugee camps and the Postgraduate Fellowship in Refugee Health pilot training programme

I am grateful to Dr Mizan Hoque, a London GP, a friend of the IENE6 project, and frequent volunteer in refugee camps, for sharing with us this informative and very personal reflection from his recent visit to the Rohingya refugee camps. I am sure this piece will move you. Thank you Mizan. Apologies for not being able to copy the beautiful photos which accompanied this reflection. Professor Irena Papadopoulos

1.1 Introduction
Family, friends, and colleagues have enquired about my recent trip to the Rohingya Refugee camps. I have documented some reflections from this very memorable visit, and have also offered glimpses of some of the relief activities we were involved with.
This reflective piece is not intended to provide intricate details of the development of the Doctors Worldwide ‘Postgraduate Fellowship in Refugee Health’. However, for those who may be interested, the official project report (which consists of more details, the relevant references, and evaluation findings) is being produced and can be shared in due course. (Please notify me via email if you would like to get a copy of this).

1.2 Background
Many have described the Rohingya population to be the most persecuted minority in the world. This impoverished stateless community has suffered under decades of discrimination, and lack of access to basic rights and services. At present, there are over 700,000 Rohingya refugees in Bangladesh who have been forcibly displaced from their homes and villages. The personal accounts of the refugees epitomises the harrowing physical and emotional trauma suffered by every man, woman and child due to this tragedy. Many had witnessed acts of appalling barbarity, including the deliberate mass burning of people within their homes, the massacre of children and adults,
indiscriminate shootings, widespread rape of women and young girls, and the burning and destruction of schools, markets and mosques.

1.3 The camps
Driving into the refugee camps in Cox’s Bazar, I sat recollecting the many news stories that I had heard about the Rohingya over the years. To be able to see the camps, and their occupants first hand, conjured up an overwhelming mix of emotions. My first reaction upon seeing the camps was that human beings should never have to live like this. There were ‘miles and miles’ of makeshift shelters, shaping the landscape for as far as the eyes could see. They were usually constructed with bamboo sticks and bits of fabric, it looked like it was something between a tent and a poorly constructed hut. The living conditions were intensely overcrowded, at times with several families living within one of these structures. Walking up to the camps, the smell of sewage was very
prominent, and the poor hygiene conditions contributed to the vast numbers of flies and mosquitoes in the camps.

Despite the desperate living conditions, these were among the fortunate ones. They were able to make the perilous journey to the refugee camps. Each had their own story of how they left behind their homes, their lives and many of their loved ones in a quest for survival. During our drive to one of the camps, an abandoned Rohingya boat lay wrecked on the beach side. The broken planks of the boat hid within it many stories. I wondered where the boat was made, and whether the one who made it knew that it would become a vessel for the survival of some of the Rohinga refugees. I tried to imagine the horrific journey the occupants of the boat had to make. The image of that wrecked boat still sends chills down my spine.

1.4 Their stories

The human stories behind the headlines are always intensely powerful. The stories I heard are far too many to recount in this piece, but as I write this, I see the faces of the people I met, each with their own narrative. I recall the 22 year old young man who showed us bullet wound injuries sustained at the back of his right calf while fleeing from his village. I recall the two-day old baby whose mother brought him to the antenatal clinic as he was not responsive. He was septic and blue, with little signs of life. The local hospital was some distance away, and despite resuscitation attempts, he did not make it to see the third day of his life. I remember feeling emotionally paralysed when being asked about the case of a 12 year old girl who had been raped and was now
three months pregnant.

My visits to the Rohingya refugee camps, as well as Syrian refugee camps beforehand, emphasised to me again and again how these were people were not dissimilar to us. Their aspirations were for a better tomorrow. To be safe, to be able to earn a living, to see their children grow up and be educated. To be respected as humans. They knew full well who they were, and where they were from. And to be able to spend some time with them, hear their stories, hold their hands and share in their tears was truly humbling.

2.1 Doctors Worldwide – Field assessments, Cox’s Bazar

Two field assessments were carried out in November and December 2017 by a team of medical specialists to assess the capacity of local NGO’s in meeting the health requirements for Rohingya refugees. Many of the charities responding to the crisis did not have health programme management experience, and there was a wide disparity in the quality of care that was being delivered. Medical needs in the Rohingya refugee camps were complicated by a number of factors, including alarming rates of malnutrition, low levels of health literacy and education, and historically low immunisation rates.

Suboptimal medical practices identified from some of the healthcare clinics included: formulating diagnoses and management plans prematurely based upon the presenting symptom alone, without taking an adequate history or performing relevant clinical examinations; adult drug dosages being prescribed for children; the absence of safety-netting advice when required; and poor instructions on how to take medications (dose, frequency and duration). Systemic problems were also identified, including of poor documentation; poor triage of critically unwell patients; and variable levels of surveillance and reporting of infectious diseases. Following consultations with a range of local and international partners, and focus group discussions with local doctors, it was determined that a priority area of intervention would be to support local Bangladeshi doctors and healthcare workers to be better equipped to respond to the crisis by means
of a training programme. As such, this Postgraduate Fellowship (PGF) in Refugee Health was proposed.

2.2 Postgraduate Fellowship (PGF) in Refugee Health The project emphasises sustainable capacity building of human resources for the healthcare response. It utilises the skills of volunteers, to help support the training, development, supervision, mentorship and deployment of local physicians to allow them to better respond through local
organisations to the complex needs of the Rohingya refugee population. A bespoke training course is being developed to be delivered in 2-month blocks to groups of 20-30 doctors. Relationships have been established with local Bangladeshi academics to facilitate joint ownership of training interventions. One of the key advantages of this project as opposed to the simple provision of medical supplies or supplementing clinical service by means of volunteers, is the strengthening of local capacity to continue to respond to the medical needs of this vulnerable community.

The Postgraduate Fellowship (PGF) in Refugee Health consists of 8 modules:
1. Introduction to Health in Humanitarian Emergencies
2. Triage and Acute care management
3. Key Communicable diseases
4. Key Non-communicable diseases
5. Mental Health
6. Reproductive Health and Gender based violence

7. Communication Skills
8. Quality Improvement in Healthcare
A core group of UK based volunteers (which consists of medical doctors of different specialities, public health experts and educationalists) began syllabus formulation and there is ongoing work on content development.

2.3 Postgraduate Fellowship in Refugee Health Pilot in March 2018, Cox’s Bazar
A PGF pilot was conducted in March 2018 to assess, logistical feasibility with partners, the use of novel medical educational approaches, the use of foreign doctors as facilitators for learning, practicalities and logistics of on-site teaching (in the health clinics) and class room based teaching.

Three local NGOs involved in delivering healthcare to the Rohingya population participated by supporting their medical workforce to partake in the teaching sessions and clinic supervision sessions. This constituted approximately 25 healthcare professionals (21 doctors and 4 paramedics).

The International Organisation for Migration kindly made their logistics hub available for the teaching sessions. There were six dedicated teaching days spaced over three weeks, within which many different sections of the PGF was delivered. Various educational modalities were utilised including simulation training with manikins, small group case discussions, and communication skills training. Local Bangladeshi doctors also delivered parts of the teaching sessions. The teaching sessions were complemented with daily clinic site visits. The faculty provided teaching and feedback in the clinic setting where the PGF pilot participants were practising. Individualised feedback was provided, and subsequent teaching sessions were informed by the faculty’s experiences from the ‘front line’.

2.4 Evaluation of Postgraduate Fellowship pilot
The formal evaluation process for the pilot is still ongoing, however the feedback data from individual sessions, in addition to the responses from the participants and the faculty strongly suggest that the intervention was well received, highly relevant, had good uptake, and has scope for expansion. The participants also found the teaching (content and methodology) to be very relevant and enjoyable. They engaged well with the teaching sessions and appreciated the ability to learn with clinicians from other NGOs. The participants felt that the clinical site supervision was highly valuable,
and they appreciated the personalised feedback. Quantitative feedback obtained from 17 participants demonstrated that over 90% of the participants ‘agreed’ or ‘strongly agreed’ that 15 out of the 17 teaching sessions delivered ‘increased their knowledge’, ‘was relevant to their work in the camps’, and they ‘liked the style of teaching and felt
able to participate’. Qualitative feedback was largely very positive, and demonstrated a very good response to the content and delivery of the training sessions. The majority of constructive feedback featured around logistical issues such as suitability of teaching location, and catering etc.

Some examples of verbatim comments included:
‘I worked with some local agencies (for training) but your people are on the top of the list’ 
‘This experience will help me a lot in a camp for patient management. I feel it was very well organised, enjoyable, more than any other agencies’
‘Teaching style is fabulous. Very informative and useful. Really like the way of teaching’
‘Complete agreement that the (PGF) content matched the objectives, I felt the modalities were appropriate’
A more detailed evaluation report will be produced for the PGF in the coming weeks.

3. Next steps
We came across dozens of NGOs, all playing a role, demonstrating a strong commitment to improve the lives of the refugees. Despite the very challenging situation, this response (albeit uncoordinated at times) must serve to strengthen our faith in humanity.
Undoubtedly a robust political solution is needed for the resolution of this, and other similar crises. But notwithstanding that, humanity, all of us, owe it to these people that we do not forget their plight. We must not allow ourselves to be fatigued by the number of crises that face us. Furthermore, the magnitude of the issue must not make us paralysed in our response, Rumi (the famous Persian poet) once reflected how oceans are simply small drops of water. Effective collaboration and a realisation that no one entity has all the answers, can greatly enhance our efforts and enable us to better realise shared goals. Our combined willpower can impact a very positive change, and history can attest to that many times over.

It is very difficult to envisage any one intervention or action that is without limitations. I remain very optimistic by these preliminary experiences and results, that perhaps, one day, the PGF can develop into an established training intervention , which is transferable to different settings and can improve healthcare provisions for refugees across the globe.

4. Acknowledgements
The entire Doctors Worldwide (DWW) with special thanks to Dr Najeeb Rahman, Dr Owais Rahman,  and Ms Georgia Venner ; Charity Number: 1122671
Teaching Faculty and Bangladesh Field Team: Dr Hafiz Uddin, Dr Abid Shoaib, Dr Mir Ahmad, Dr Sayyada Khaki, Dr Mohammed Khaki, Dr Jobayer Chisti, Dr Vikarunnessa Begum, Mr Sayeed Ahmad
DWW volunteers and content developers
Photography – Dr Hafiz Uddin
Logistical Support – Dr Razwan Ashiq, and Dr Imran Siddiq
Rt Hon Stephen Timms MP for East Ham
Rt Hon Shelim Uddin Member of Bangladeshi Parliament
Mrs Jayada Begum
Lime Tree and Sinnott Healthcare; Wordsworth Health Centre and UCLPartners; for kindly facilitating leave arrangement to make this trip possible


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