The Rohingya people have suffered decades of violence in Myanmar. Since 1982, they have been denied citizenship, making them the world’s largest stateless population. In 2017, the largest wave of indiscriminate and violent attacks on Rohingya communities in the Rakhine state by Myanmar’s army resulted in 742,000 registered refugees fleeing to the neighbouring country of Bangladesh. About one million Rohingya refugees now live in 33 makeshift camps sprawled across the coastal area of Cox’s Bazar, and about 30,000 refugees in Bhasan Char, a remote island nearby. The violence has not stopped in the Rakhine state and is reported to be getting worse, however, the border with Bangladesh is now closed with no plans to reopen. 

I was once told by a well-experienced humanitarian worker in the camps, “if you want to learn about public health, work in the Rohingya refugee camps.” Living in overcrowded, “temporary”, and small makeshift shelters, the Rohingya have been highly vulnerable to disease spread due to a multitude of factors such as poor access to water and sanitation, strict government policies affecting livelihoods and movement, dwindling humanitarian aid, a rapidly growing population density, environmental disasters¹, language barriers and cultural differences (e.g. understanding of health and illness). Combining these factors, the population has unsurprisingly faced a wave of infectious disease outbreaks including measles, diphtheria, mumps, acute watery diarrhoea, cholera, varicella, scabies and COVID-19 since 2017.

The Rohingya people have long distrusted Myanmar’s healthcare system and since arriving in Bangladesh, the pandemic response compounded an already vulnerable relationship between health workers and patients. For example, in other research, patients reported distrust and fear of healthcare providers and felt they received poor care. There was also an increase in rumours and fear spreading amongst communities, viewing health centres as places where they will be purposely killed or kidnapped. 

There is limited research on the experiences of frontline health workers working in refugee settings during outbreaks, and even less on refugee health workers. My PhD explored the complex and multifaceted nature of frontline health workers of the Rohingya response including their emotional and physical labour, risks and improvisations of care practices. This blog post reflects on the findings for the Rohingya refugee CHWs.

Invisible burdens on Rohingya CHWs

In my conversations with the CHWs, they highlighted their substantial yet undervalued emotional and physical labour which was heightened during outbreak responses. For example, CHWs were heavily relied on by the Rohingya communities for health education, language translation, referrals and guidance on the rapidly changing health policies. During the COVID-19 pandemic, one of their main priorities was to debunk complex misinformation, share scientifically accurate information, assist vaccine campaigns and provide non-stop support to community members affected by COVID-19. This required spending a significant amount of time speaking with households and building trust. 

“It was extremely difficult to convince those who tested positive to go into isolation centers during the initial stages of the pandemic in 2020. There were rumors circulating that people would be harmed or even killed in isolation centers.”

Focus group participant, Rohingya CHW

Barriers to training and employment

Rohingya CHWs experienced workforce discrimination daily. They expressed the lack of opportunity for professional development compared to their national colleagues and precarious government policies prohibiting them from being formally employed. The Rohingya CHWs are considered volunteers receiving small stipends depending on their skill level. This has created barriers for I/NGOs to hire and train CHWs. Further, Rohingya CHWs also face movement restrictions and risky checkpoints preventing them from attending training outside and even in between camp borders. I was continually struck by how many Rohingya CHW participants stated that they did not receive formal² health training, especially during the COVID-19 pandemic. Despite access barriers, there seemed to be insufficient efforts to provide rigorous training for CHWs in the camps, even for COVID-19 safety. Instead, many who I spoke to received brief, informal training from Bangladeshi colleagues in small clinic spaces. Participants further described their learning experiences as a “copy-paste system” with no opportunity to learn or develop, only to relay information to their communities. They rarely received a record of training completion or learning materials to reference. Participants told me that current government policies restricted any professional certification for Rohingya people.  

“When the [COVID-19] outbreak commenced, our supervisors initiated discussions and provided guidance on how to navigate the situation. However, there were no formal training programs arranged, and we did not receive any professional certifications for the knowledge imparted during these sessions.” 

Workshop participant, Rohingya CHW

Inequitable protection of health workforces

In terms of infection, prevention, and control (IPC) measures, when working during outbreaks such as COVID-19 and scabies CHWs often felt neglected by management, unsafe during outreach activities and undervalued when compared to their colleagues in clinical settings. 

“We didn't always have access to PPE, it was only worn inside the hospital, not during community visits. As we witnessed the rising death rate due to COVID on social media, concerns about our family's safety grew. Being health workers, the fear of unknowingly contracting COVID and transmitting it to our families led to precautions. For two months, I didn't allow my children near me.”

Workshop participant, Rohingya CHW

In addition, these fears of personal safety were compounded by an alarming increase in violence from gang-related activities such as threats, killings, kidnappings and the emergence of terrorist groups. Those with a professional role in the response, such as CHWs receiving their volunteer stipends, were commonly targeted.  

“We always approach community visits with an underlying fear, considering the potential for aggression.”

Workshop participant, Rohingya CHW 

Moving forward

During crisis response, it is rare to find examples of humanitarian responders and governments prioritising the development of strong refugee workforces. They focus on refugees as people ‘to help’, not as people to be a part of working members of society, even during protracted crises. An obvious reason is that humanitarians are confined to inflexible UN systems designed to provide aid, not build communities. Additionally, national governments hosting forcibly displaced populations may not be willing or capable of acknowledging their tremendous potential. We see this in my examples above where Rohingya refugee CHWs are often overlooked in the humanitarian response yet vital to everyday health practices. 

Despite significant efforts by UN agencies to support CHWs in the camps, they arguably remain legally invisible and deprioritised in the health sector. Humanitarian sector leaders and coordinators, i.e. the Health Sector (led by WHO) and the Community Health Working Group (led by UNHCR), must advocate for better recognition and support for Rohingya CHW labour practices and protection to better respond to the complex health needs in the camps. It is also an opportunity to build a strong health workforce when or if they return home to Myanmar. Finally, as already advocated in our previous study led by Dr Jennifer Palmer focusing on South Sudanese refugee health workers in Uganda, a focus to include the protection and development of refugee health workforces in frameworks such as the Global Code of Practice on International Recruitment of Health Personnel, and WHO’s newly published national workforce frameworks is crucially needed.  

Georgia Venner, PhD candidate, LSHTM

¹ Since writing this, the camps have faced landslides killing 7 and affecting 8,000 refugees due to heavy monsoon rains. Since 2017, they have been affected by 770 landslides.

² Defined as training provided by an expert training facilitator or someone who has participated in a Training of Trainers workshop.