The health of forcibly displaced people across the globe is often overlooked by mainstream media as a result of their marginalised status. However, multi-disciplinary analyses of the barriers to health faced by refugees are important to give populations a voice. This segment in a series of articles, entitled 'The Refugee Health Crisis', will provide on an overview of the health crisis of the Rohingya refugees in Southeast Asia.
Migration and global health is a reality, and it is one of the defining issues of our time. With two billion people living in countries affected by civil unrest and ongoing conflict, the numbers of forcibly displaced persons are at some of the highest ever recorded. Though distinctions between persons on the move can be blurred, this series will take the identity of a 'refugee' to refer to populations of forced migrants who have fled their country of origin to seek protection from human rights violations in their nation state.
Since August 2017, East Asia has seen a mass exodus of over 700,000 Rohingya refugees to the western coast of Bangladesh. Although their active oppression has been occurring for decades, they are now fleeing systematic military persecution which is taking place against them in the Rakhine State of Myanmar. An acute refugee crisis has been created, with well over half a million displaced persons living in Kutupalong-Bulukhali, the world’s largest refugee camp. Though the Rohingyas have lived in Myanmar (formerly Burma) for centuries, they have become a stateless ethnic group who are denied citizenship under Myanmar law. The government justifies this with claims that they are illegal Bengali immigrants. These communities are not only socially and economically marginalised, but also experience poor access to basic services, resulting in several key public health challenges; prevention and control of communicable diseases, severe malnutrition and water-borne diseases.
Unfortunately, both the Myanmar and Bangladeshi governments have failed to provide the economic, social and cultural rights (let alone any civil or political ones) that a human being should expect to receive. The structural barriers put in place by a life of social and political precarity directly increase the vulnerability of the displaced population.
It is important to note that there is a distinct lack of official data for Rohingya populations – partly due to their status as a persecuted minority and partly due to their active exclusion from political life – which makes it somewhat difficult to assemble a wholly systematic overview of their health. When in Bangladesh, Rohingya children are not registered at birth, which deprives them of a legal identity which partly explains the lack of data. It also leaves them often unable to obtain a refugee status.
The right to attain a certain standard of health is a human right. However, the denial of responsibility on the part of both the Myanmar and Bangladeshi governments have overshadowed these rights and abandoned the Rohingya people outside of legal systems and therefore outside of mainstream systems of healthcare. This is deliberate and detrimental inactivity of the state. The Rohingya have been consistently removed from systems of government; left in a political limbo where they are stateless in their nation-state and refugees in their host state. The suffering that defines the refugee health crisis must be understood to be linked to discriminatory conditions which determines who suffers from human rights violations.
'Why is it that they are being allowed to die from avoidable diseases such as diarrhoea? When was the last time a relative or friend of yours died from a bad bout of diarrhoeal disease? The answer is never.'
The vulnerability of the Rohingya refugees to preventable disease is a result of the fact that they are an abandoned population. Diphtheria is a communicable respiratory tract infection. It is very rarely seen in developed countries. In the UK for example, we are routinely vaccinated for diphtheria as a child. And yet, in a 2018 report on infectious diseases the Lancet suspects that diphtheria may in fact have been endemic to the population as a consequence of a lack of access to vaccinations in Myanmar; lack of access to a simple vaccination which prevents the spread of a life-threatening disease.
The Rohingya refugee camps were only initially built for temporary use, which has led to a situation where conditions are unsettled and overcrowded. The health problems are all related to these highly impoverished and unideal living conditions, with a lack of shelter combined with inadequate healthcare and poor sanitation contributing to the poor health indices. For example, UNICEF documents how in one camp the water supply is separated from the sewage by a low wall. Children are forced to walk through this excrement in bare feet. The Rohingya are forced to engage in these behaviours that leave them more at risk from preventable diseases as a result of the structures around them.
Poor socioeconomic status is, as always, a large factor in the ill-health of this population. However, the issue with refugee health is not as black and white as economics. The unfortunate reality is that the Rohingya remain a stateless minority and are powerless to determine their own lives. It is not black and white because they have very few opportunities to earn money – no land for agricultural use, no access to formal education, and restrictions on travel within and outside of the camps. Humanitarian agencies work hard to provide adequate aid for the refugees who are dependent on them for shelter, food and healthcare. But there are only so many resources to go around.
The fact that the Rohingya are mostly suffering from preventable diseases and health problems resulting from a lack of sanitation and nutrition constitutes a particular assault on their dignity. Why is it that they are being allowed to die from avoidable diseases such as diarrhoea? When was the last time a relative or friend of yours died from a bad bout of diarrhoeal disease? The answer is never.
'Their vulnerability to disease is not an accident. Their vulnerability to disease is an intricate blend of social, economic and political aspects in which poverty and lack of citizenship are the primary and determining causes. '
Controllable diseases can be controlled. They are by no means inevitable. So, suffering from preventable health problems cannot escape our attention. The poor health indices of the Rohingya are a protracted result of repressive political forces that have excluded their entire population from political, economic and social life. The blatant inaction of governments with regards to health services and to any kind of formal registry data has created a system whereby the Rohingya have suffered decades of systematic exclusion.
Coming from extreme destitution and oppression in their nation-state of Myanmar, the Rohingya have found themselves now trapped in a cycle of poverty in which the structures they live in are creating sources of unfreedom, most notably in education and health. These limitations are diminishing the future of Rohingya children and risk them becoming a lost generation. The lack of apparent regard for their education is just one example of how basic rights have been removed from the lives of these refugees. The Rohingya suffer with little to no opportunity for individual agency, and so cannot overcome the structural inequalities that they face. The combination of a denial of healthcare and education has led to a situation in which much of the community are illiterate and uneducated on disease prevention. Any real development towards instilling agency and dignity back into the lives of the Rohingya requires these major sources of unfreedom to be removed.
In a previous segment of the Refugee Health Crisis series, I discussed the status of Syrian refugees in the Middle East. Whilst the two crises do relate in the deliberate deprivation of access to healthcare on the part of the state, the fact that the Rohingya are mainly settled in refugee camps rather than being absorbed into host communities has produced a different health crisis with different key public health challenges. The exclusion of Rohingya people has created a system of structural inequality that exacerbates the vulnerability of the refugees by removing their autonomy and creating major sources of unfreedom that limit their access to any basic quality of life.