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Myanmar’s Rohingya: ‘At a Certain Point You Can’t Treat Hopelessness’

BANGKOK | 23 September 2022

Welcome to the podcast of Reporting ASEAN, a space for talking about things that are truly Southeast Asian.

Today, we talk about the increasingly insecure, precarious life for the Rohingya refugees in Bangladesh – and how the political paralysis around their situation is raising grave health and humanitarian concerns. 

This is your host, Johanna Son. I spoke to Paul McPhun, who is director for Southeast Asia and the Pacific for Doctors Without Borders. Through more than 30 years, he has worked in various humanitarian emergencies in Africa, Latin America, the former Soviet republics, as well as Chechnya.

We spoke soon after the fifth anniversary of the largest exodus of over 750,000 Rohingya from Myanmar on the 25th of August 2017 – a day that is now called Rohingya Genocide Remembrance Day. Entire communities fled across the border to Bangladesh from that day on, as the Myanmar military carried out scorched-earth operations following an attack by an armed Rohingya group in Rakhine state.

Today, nearly a million Rohingya live in restricted settings that are sprawled across 16 kilometres of camps in Bangladesh.

The area is the world’s largest refugee camp – and the mainly Muslim Rohingya are the largest stateless population globally.

McPhun tells us how the status quo is taking a steep toll both on the well-being, physical and mental, of the refugee community – and the minimum human standards that are needed to maintain a degree of decent living. Medical professionals, he says, cannot quite treat the condition of hopelessness.

The option does not exist for the Rohingya’s repatriation to Myanmar, which tried to delete their identity by making them stateless four decades ago and is now run by the same military forces that drove them out. There are also no takers, Southeast Asian countries included, for their resettlement.

In other words, they are stuck – literally, figuratively and politically so. Here’s our conversation.

Johanna Son, Reporting ASEAN: The Rohingya is one of those issues where everybody knows that there is a problem. So I wanted to start by asking something that maybe we don’t read about enough, which is that – what is daily life inside the camps like? And in particular, what kind of challenges are coming up that you’ve been seeing more and more?

Paul McPhun: I think it’s a really good question. There are several aspects to daily life in the camps. I think the first one people have to understand is that post the period of COVID, that the camps have gone from being the kind of open-camp settings where there was freedom of movement in and out, to a closed camp setting. A closed camp setting means that this camp, this massive area, 16 kilometres of camps within camps, is entirely encircled with guardposts and fencing, and razor-wire fencing. And the camps within camps are all contained and encircled as well, so it’s a setting where there’s very little freedom of movement. You’re assigned a particular camp, you’re supposed to receive your services to sustain you in that particular area of the camp. 

And the reality is, of course, that the distribution of services – which is not surprising – the distribution, the quality and the quantity of services varies a lot. And so that means people have to move around from one camp to another if they’re seeking something that’s not available to them. 

So I guess daily life is partly about survival. People are almost entirely dependent on aid, or selling the aid that they receive or bartering or exchanging it, and then trying to find other ways to make income. The Rohingya don’t have the right to work currently. So that means that anything that they do is voluntary, and there may be a stipend, so they work for local organizations for very little, or they try to find any which way to get in and out of the camp so that they can do seasonal work. And that means that they have to take quite a risk to do that and they may, you know, they may be extorted, they may have to pay bribes. (It’s in) the informal sector, you know, so that because of this level of vulnerability, they’re fearful and they feel vulnerable, and they also feel exploited. And so they fear, obviously, for the security and safety of their children. 

The camps are not safe settings. People expressed to me, a lot, about the fact that social cohesion has collapsed. People basically don’t trust each other, because you don’t know who your neighbour necessarily is. . . So people feel constantly unstable, insecure. And over the top of all this, of course, they’ve been living in these kinds of precarious conditions now, this largest number (of refugees) for the last five years, (this has been) a really, really long time – and they don’t see hope for change. 

A Rohingya woman, in early labour, at the Goyalmara Hospital delivery room, which is run by Doctors Without Borders. Photo: Doctors Without Borders

So that’s the last concept I would express is this feeling of despair, hopelessness. And we see that in our mental health clinics, we see patients come in constantly and there’s only so much we can do to treat them, you know, to improve their mental health state because the circumstances in which they’re living is not changing. If they had hope for a future or hope for a change, that might be different. So we feel that even the care we can provide, and particularly the mental health care we can provide, you know, at a certain point only has a very limited impact, because (the) circumstances and situation is simply unchanging. If anything, it’s starting to get worse.

Johanna: When you talk of mental health support, what kind is that? Is that mostly counselling? And what kinds of people come in, like men, women, young people?

Paul: Exactly, it’s individual, one-on-one counseling sessions, psychological first aid, but also group therapeutic sessions. So we do both. And with individual sessions, we see a lot of children, we see a lot of mothers, but we also see men, adult men and young adolescent men. It’s particularly difficult with children because they show the signs and symptoms of mental health disorders because many, many of them have grown up in this setting. Young children under five have known nothing else. And then other children, you know, they suffered significant trauma when they fled from Myanmar, and they witnessed horrific things that no child should ever see. So on the one hand, they suffer from post-traumatic stress disorders and acute problems, anxiety, sleeping disorders, depression, things of that nature. 

But interestingly, what we see now, more and more, is it’s this hopelessness, it’s the fact that they have no agency, that the situation doesn’t change. And parents, particularly, despair that they can’t help their children, they can’t improve the lives of their children, they can’t protect their children, they can’t change the circumstances for their children. So this hopelessness really eats away at them. And again, we see that in more and more severe forms of anxiety, depression, self-harm, things of that nature, which is, I have to say, quite common, a trend of falling care, a deterioration in your mental well-being over time when you’re subjected to living in containment-like settings.

Johanna: You were also talking about a rise in scabies, dengue fever. What are these signs of?

Paul: One of the things that we see, and again it’s not surprising – we’ll probably talk about that – but (there has been) a drop in funding commitments that are going into Bangladesh. Therefore, the distribution, the quality and the quantity of services available we see gradually deteriorating. I think it was good that a lot of the infrastructure that was put in place has been quite successful. So it’s quite impressive that there has been a big effort to create waste management, water facilities, pathways, drainage roads, etcetera. 

We recently undertook a quite comprehensive sample survey across 19 camps. And although we could say on the one hand, that the quality of water in these camps has actually improved, the availability of that water has really gone downhill. So the access and availability, when we surveyed people, was at about 50%. So 50% of those surveyed said that they didn’t have access to a continuous available source of water. Seventy-six percent complained that the toilets they use are overflowing, and 88% had inadequate access to sanitation facilities. And what this tells us is, you know, that the very basic fundamental building blocks that you need in place, from a public health perspective to keep a population as healthy as possible under these precarious conditions, are starting to erode. 

And what we see in our clinics as a result is really quite a spike, in terms of, first of all, skin infections, so we’ve seen quite large outbreaks of scabies across the camps. Just between March and June, we treated 42,000 cases of scabies across two camps and two facilities. And so that really shows something’s going wrong in the local environment in terms of living conditions and access to clean water. And we’ve seen quite an increase in acute watery diarrhoea, so (that) particularly affects young children.

And you can see the accumulated effect – between 2019 to 2021, we saw a 50% increase in cases of acute watery diarrhoea. So, the health indicators really stand out, these challenges of maintaining these kinds of systems and services really, really need to be dealt with.

This just illustrates that to maintain a population of the size, over a million people, in a camp setting that’s furthermore in a contained camp setting where the shelters because of the temporary nature of this response – because the hope is that they will return to Myanmar – the shelter and materials and everything used is of a minimal standard. So it can, over time it starts to fall apart and degrade, and it becomes very, very hard to maintain a sort of minimum standard of hygiene practices across the camp.

Johanna: I hesitate to use the word compare. But how does the situation of the Rohingya in the camps in Bangladesh look to you, from the perspective of your previous experience in other humanitarian emergencies? 

Paul:  It is very hard to compare one context to another because of course the circumstances are uniquely different generally, depending on the setting you look at. But any large refugee camp-style setting, of course it shares all the same challenges, you know. You’ve got to have adequate shelter, you’ve got to have a minimum access to clean, drinkable water, you’ve got to manage sanitation. And these are always the fundamentals that you’ve got to have in place if you want to try, and on top of that, then build resilience in the population and try and maintain some level of health and well-being. And in large camp settings like what comes to mind would be what was the world’s largest refugee camp in Africa at least, the Dadaab, on the border between Kenya and Somalia, you know, there was a certain point (when) there were 500,000 refugees there. And many of the problems were similar from a health perspective. It’s very hard to prevent outbreaks and you get seasonal problems, it’s hard to maintain a certain level of quality.

The difference there, of course, was this was not a contained environment. And people, although their rights to work were limited, they created their own city in the end, and this camp has been there for decades. So at the end of the day, the infrastructure is very, very different. It’s more permanent. People have, you know, their own livelihoods, so at least to a large extent, some of them are able to fend for themselves and not only depend on the assistance that they receive. There are many other camp settings around the world, like I’ve been in – probably one of most recent was Jordan, the Zaatari refugee camp (which opened in 2012 to host refugees from Syria). And there you see a completely different approach in a very, very well structured and organized camp setting, people assigned very clearly into very well established and designed camps to manage that huge influx, and that was around 70 or 80,000 refugees at the time. 

The difference with Cox’s Bazaar, of course, is that nobody anticipated the mass influx of 700,000 people in a matter of weeks, and the location that was allocated to them was very inhospitable. And so as a result, you’ve got this massive camp setting emerged in a very precarious way in quite a hospitable place where you would never choose by choice to set up a new population. It’s fraught with problems, and so a lot of that has had to be overcome. 

A treatment facility for human waste in the camp. Photo: Doctors Without Borders

And the result is, you have this very difficult place to work. And now we have the world’s largest refugee population, a million and growing, in that setting. So again, like I said, very difficult to just simply draw comparisons. But from a health perspective, it’s very much the same health markers that we look out for, it’s very much the same minimum standards that we need to meet. 

The types of health services  – we have the full spectrum in Cox’s Bazaar, of course, from inpatient department care, emergency care, outpatient department care, reproductive health care, safe deliveries for pregnancies, mental health care, we treat chronic diseases – you know, what you need is a huge comprehensive approach. It’s not just about one or two morbidities for a few months, this is really a health system inside these camps.

Johanna: What has the funding situation been like for the camps, especially in these times? I’ve seen the figures for the humanitarian appeals for Myanmar itself, and even that has quite a shortfall.

Paul: When I was in Bangladesh, nearly everybody I spoke to, the embassy staff, UN agencies, NGOs, local government and people were talking about their fear of a funding crisis this year. 

I think (in) my last conversations with the UN, they were less concerned, they felt that the pledges would be met this year, or at least met fairly well. But that remains to be seen. What I understand is we’re at about 50% of the funds required for this year have been met, and that’s a significant shortfall currently. So I don’t know how that’s going to translate in reality to the response on the ground. 

Over the last years, we’ve seen a decrease in funding, particularly since the onset of COVID. That impacted where money was going and the choices that were being made. Then we have the Afghan conflict, and that was a big diversion. That’s distracted international governments’ attention. And now we have Ukraine, and that has significantly changed the priorities of a number of governments that have been supporting not just Bangladesh with this huge responsibility that it’s taken on itself, but other countries, as you say, like Myanmar. 

A typical shelter made from bamboo and tarpaulin at the Kuttapalong refugee camp at Cox’s Bazaar district, Bangladesh. These are usually 100 to 200 square feet in size, cramped together. Photo: Doctors Without Borders

The other things now going forward into the future is we already see the funding, the funding commitments going downhill. Attention is clearly elsewhere; the priority is elsewhere. Now we’re seeing huge inflation. So for Bangladesh alone that invests huge amount of money each year to support this refugee population, it’s going to make it a lot more expensive to do so, as it will for other countries, and related to that the cost of supplies and services is going to increasingly go up. And yet the population is not reducing. If anything, it’s growing still. This is why, in my op-ed, I described the situation, and this is just the economic aspect, as one of the drivers of this pressure cooker.

At a certain point – and we’ve already passed that – maintaining the same approaches as now and expecting to receive the same kind of investment is unsustainable. And it’s just going to get, I think, very much harder in the coming years, to manage this response in the way it’s currently being managed.

Johanna: You’re basically saying that the situation has reached a point where things cannot just go on like this. In your op-ed piece, you had used the words “increasingly unsustainable”. You were also saying that looking at resettlement is a pragmatic reality at this point ­– or perhaps one could call it a reality that’s not being said aloud, or pursued. So, I don’t know, how realistic is that?

Paul: I know I’m being controversial when I describe refugee policies in the region as being draconian, and I’m being intentionally strong in that term. Because one of the problems as I see it is as a region, the region hasn’t signed up to the refugee conventions. We’re not affording the same level of protection that refugees, asylum seekers may receive elsewhere, and the one exception is Australia. But Australia, on the one hand, has signed refugee conventions and should be offering protection but has draconian policies that prevent that from happening, by pushing boats back and preventing people to arrive in Australia in the first place. So I really see this as a huge part of the problem. 

Now, the solution, everybody understands, is you’re not going to resettle a million people in the region and that’s very, very clear. Even if there were a more ambitious resettlement programme, and a number of countries signed up to support that, it would only have probably a small impact on the overall challenge that Bangladesh is facing currently, at least in Cox’s. 

But it would, I still think, be meaningful that we really try and shift the attitudes currently, and the political position currently, because as I see it at the moment, the policies are very much the reverse. They’re entrenching securitizing borders, preventing people to have access and not affording people protection, labeling people illegals. I don’t fingerpoint any particular country and I would include Australia, in this, you know, it’s the reverse approach in my mind to what we need currently, because we have a pressure cooker, we have a problem. These are fellow humans who are suffering as a result, and there are no easy solutions to see them repatriated in Myanmar. 

And I think everybody agrees the situation there, if anything, is deteriorating currently and safe conditions for return are not around the corner. But in the meantime, there’s nothing being done to pursue alternatives, even if those alternatives can have a minimal impact, that could have an impact on perhaps some of the most vulnerable, and that would at least be a stance, and it would shift the momentum from not taking responsibility to assuming some collective responsibility regionally. 

Johanna: You’ve asked the question whether humanitarian workers are being “complicit in a system of containment, or repression or apartheid even”. Can you explain why you use those words in relation to the situation in the camps in Bangladesh? In many ways, the situation in Myanmar now has become even more intractable it seems – the idea of repatriation or meaningful repatriation at this point?

Paul: First of all, for anyone to critique others, we have to critique ourselves as well. It’s incumbent on us to also look at our own actions and what we do. And as an organization, and particularly an organization of doctors and nurses and psychologists, we have to ask ourselves a question: are we are we helping people and reducing mortality, morbidity? Are we potentially doing harm to through our actions? And when we’re in a setting where we see patients, we treat patients, they return to the setting, they become reinfected or they’re suffering mental trauma, and there’s nothing more we can do for them because of the situation that they are in, we have to ask ourselves – are we becoming part of a system that’s maintaining them in this terrible sort of status quo?

And then my reflection is that at the end of the day, we also, we’re just trying to do our best, I think everyone is trying to do their best. The fact that Bangladesh opened its borders in the way that it did is remarkable, and that they’ve taken responsibility for such a huge population, and are continuing to host them. (It’s) the only state that has really opened its borders in this way. . . and yet they often face the majority of scrutiny and critique because of course, all the problems are around this population that live in these very difficult circumstances. And the scrutiny is not necessarily elsewhere, where states have chosen to do nothing, or very little. 

So we need, we need to step back. And by stepping back, I’m reflecting that at the end of the day, this is Myanmar’s responsibility. It’s the actions of the Myanmar military that led to this mass exodus and it’s the inaction since then to address their wrongs that leave us to deal with this very, very complex problem. And as humanitarians it may be frustrating and challenging. 

We can have an impact on the patient in front of us, and I firmly believe we do and we must continue to do that. But we can’t have an impact – we have very, very little likelihood of having an impact on the root causes of this problem because they require political solutions. So what we can do is provide the evidence to say things continue to deteriorate, this situation is not going away, and there will be a cost of this political inaction not just from Myanmar, but from the region and the international community. And that cost down the road is probably going to be far, far higher than increasing our investments now, politically, economically, etcetera.

So my call to action is to say we have to try to do more, however difficult it’s been, however challenging it seems, however hard it seems. At the end of the day, the situation in Myanmar for the Myanmar authority is not sustainable either, and so there must be political avenues, political leverage, political support that can be given to bring about a change in the circumstances.

Johanna: ASEAN continues to discuss the issue and for example, in its foreign ministers’ in July, its documents still mentioned voluntary repatriation and continuing with the needs assessment processes in Rakhine. Perhaps its view is that ‘talking about it is better than nothing’. But then again, isn’t this a bit like advocating for something that one knows is not going to happen, or because it’s not going to happen, and that’s fine?

Paul: I’m not an observer in ASEAN meetings, but of course I’ve spoken to people who have much more contact and access than I do. And the sense, the understanding that I get is people just are frustrated. They feel that they have tried a lot. They don’t really have new solutions, new ideas and they have many other pressing priorities and it’s easier to move on to those other pressing priorities. And again that’s why I flagged that this is a problem that’s not going to remain contained in one country or a couple of countries.

Sooner or later this is going to be a much larger problem that the region will be facing, so it’s not to say that no one’s doing anything or that nothing at all is happening. But it really does seem that there’s people at the moment, they feel that there’s very little hope to make meaningful, impactful change, and we really have to resist and push against that. 

I think there needs to be a concerted effort to take stronger leadership across the region at the level of ASEAN, really look to China to provide strong leadership – far better equipped to do so perhaps? – and then look at meaningful ways to support them as a unique approach that perhaps other states are not in a position to take on. But the sense that I get is that this really has moved into the ‘too hard’ basket. It’s going to come back, and it’s going to come back much worse.

Johanna: Would you agree then that this is a humanitarian emergency, but political considerations are becoming the first consideration, or driving the lack of response or taking precedence over humanitarian needs, clearly?

Paul: With most major crises, particularly conflicts, the solutions are political, and humanitarian action is just a response to those crises. The solutions are always political. It’s about political will and political willingness and timing, influence and the benefits of change. 

It really comes back to the fact that everybody I spoke to, including the Rohingya, they see that future being a return to Myanmar, and (there is not) any disagreement from anyone that that’s really the only way that this current crisis will be resolved. So it really comes down to how, under what circumstances could return take place in a safe and meaningful way, where people would actually have the confidence to return because the Rohingya families I spoke to, on the one hand they say they want to return but on the other hand, they say ‘You know, we’re not naive. Conditions were terrible when we lived in Myanmar. We don’t want to swap one camp setting, one containment setting for another one that may be worse, and we don’t want to fear that our children or brother or uncle is taken away in the middle of the night,’ and that’s their experience. 

So people are not simply going to return because we say they should, or say they shouldn’t. I certainly say they shouldn’t. I don’t think the conditions are there now, at all. That’s not what we witnessed as medical care providers either. But clearly, in the long term, this is the ultimate challenge that has to be reconciled.

Johanna: From the perspective of someone from MSF, what kind of challenges and experiences do humanitarian workers have when working with people in camp situations, also in terms of their own mental health? What is it like to do this kind of work?

Paul: it’s interesting because I draw parallels with what I see happening in Cox’s Bazaar with what I’ve personally seen happening in Nauru, which, you know, we had a program in Nauru providing mental health support to asylum seekers, refugees in the Nauru population and Australia was holding the refugee and asylum-seeker population in offshore detention. I compare that also to our experience in Italy and in Greece, and similar camp settings where refugees, asylum seekers have arrived by boat from North Africa. 

What we see is a real deterioration in their mental well-being, and the common thread between them is this lack of any clarity over their future. So though they’ve been through traumatic events, and we can help them deal with those kinds of traumas, there’s this pervading sense of hopelessness. It’s ultimately this feeling that there is no solution, that they have been entirely abandoned. And that’s what ultimately has an impact – that at a certain point you can’t treat – because you can’t change the circumstances. 

And so when I speak to our own staff, at a certain point, they get affected by this. It’s very, very hard for them. They start to question what they’re doing as counsellors or psychologists, you know ‘why am I here if I can’t help people?’ And it’s really tough, it’s really tough on them. So although it’s essential that we’re still there . . . it’s these cases where they see people continuing to deteriorate, despite the kind of lifeline we’re trying to offer and the mental health services we’re trying to provide (that are tough), because at a certain point that type of clinical care, it loses effect when the environment simply doesn’t change. So I’ve spoken to a lot of psychologists who, they question ‘maybe we shouldn’t be here, because I don’t feel like I’m actually fulfilling my medical responsibilities well’.

Johanna: It feels like the world has maybe accepted that Myanmar is about, you know, a lot of bad news, yes, and there is even more bad news, but this is the way it is

Paul: It’s just important to understand this isn’t a crisis that started five years ago. This latest exodus is a sort of culmination largely, I think, of years and years of exploitation, discrimination and violence and exclusion, etcetera, etcetera. And it makes it easier to understand, perhaps, why it is so much harder to come up with a real meaningful solution or change where the Rohingya would have their rights reinstated, their citizenship, their right to citizenship reinstated, to be able to enjoy the rights that anyone else, any other individual, enjoys who is a citizen of a state.

This is what makes them so much more vulnerable – that they have no one assuming a responsibility, a legal responsibility and a protection responsibility, for them. They have governments hosting them but they lack that legal status and therefore they’re described as a stateless population, so (that’s) yet another vulnerability that they have to live with.

Johanna: Thank you very much, Paul, thanks a lot for the time. 

Paul: You’re very welcome, Johanna. Lovely to meet you.

(END/Reporting ASEAN)

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