
	WATER WATER EVERYWHERE... March 25, 2008 Water is a constant issue in the camp. All year round salt water from the tidal river Naf floods at least 10% of the homes twice a day. In the rainy season 80% of the dwellings become submerged. And yet all year round the scarcity of clean drinking water is a huge problem. Adrien, the logistician and water and sanitation (WATSAN) expert, had a meeting with some of the elders of the nearby Lada Bazaar village this morning. The meeting took place at the village school. This is one of the six local sites chosen for the construction of wells because of the proximity to the new Tal site. I joined him and the WATSAN team. There were quite a number of local dignitaries to meet us at the school showing how important this well was to the community. After the pleasantries the Médecins Sans Frontières WATSAN team met with a couple of local labourers to map out the best place to position the well on the school grounds. A spot was chosen which would adhere to Médecins Sans Frontières guidelines, which include keeping a certain distance from latrines, and the labourers got to work. Adrien and village elders supervising the dig for water Adrien explained how finding water could mean drilling forty feet, the average depth of the water table in this part of the country. And if there was no success in this position the process would have to be repeated in another spot. There were no hydrological surveys of the area so water exploration can be quite arduous. As one of the labourers started digging a hole with a long sharp ended metal rod, I wondered just how many days it would take to find water. In no time, as we chatted with the school teachers and elders a really deep hole had appeared. The other labourer ran off with two large empty 5 litre tins attached to the ends of a branch balanced across his shoulders. He returned with water in the cans, which must have been really heavy, and began to help dig an adjoining square hole a foot deep. The water was then emptied into this square hole to form a mini reservoir. Adrien explained how it could now be used to soften the soil so they could dig deeper. Three branches were then dug into the ground and the metal digging implement balanced across two nails which had been knocked into one of the branches. Voilà, in less than 5 mins they'd assembled a basic drilling device. We left them driving metal tubing into the deep hole and adjourned to the school for some tea. As we left the school Adrien explained the importance of supporting this community in preparation for the relocation of the Tal camp to near their village. The WATSAN team are trying to mitigate against the increased pressure of the natural resources that this move will create. Provision of water for the host community also fulfils Médecins Sans Frontières’s principle of non-discrimination where services are available to all who need it, Rohingya and Bangladeshi alike. Collecting water is quite an ordeal Chickenpox March 24, 2008 Last night at dinner we shared our childhood chickenpox stories. Our personal horror stories certainly proved that the disease didn’t just leave physical scars. The subject had arisen when I’d asked to sit in on Emmanuel’s next training session with the Hygiene Promoters (HP) which happened to be on chickenpox. Today I was introduced to the seven HP’s in the training room at the clinic. Shawrna was the crucial conduit, translating Emmanuel’s passionate delivery into Bengali and the HP’s responses into English. Emmanuel's style of constant questioning ensured he had everyone’s attention. He soon filled up the white board with their responses. After reaching consensus on what chickenpox actually is he focused the HP’s on how to communicate this to the Rohingya. He was constantly reminding them “let’s keep it non-clinical” and forcing them to focus on the thought processes of this population. At the end of the session Emmanuel requested that someone volunteer to take the chickenpox message to the camp this afternoon under his supervision. Manashi Rani, one of the most vocal participants of the training session, took up the challenge. It just so happened that her section of the camp is at the farthest end of the camp from the clinic. So that afternoon we all set off along the busy road causing much commotion as we went. There were the usual swarm of Rohingya who seem to accompany “farlangs” (Bengali for outsiders) around the camp. As most of our chaperones were under 10 we had to be extra vigilant on their behalf and watch out for the speeding traffic. Community health training in Tal dwelling - Emmanuel on bottom right. When we arrived at the house where the training session was to take place I wondered how we were all going to fit in. The word had spread so this relatively large house by camp standards, measuring approx 3 metres squared, had 10 women already gathered. As another seven of us squeezed into the home the plastic sheeting, which formed the partition walls between the homes, came into its own when it was unpinned allowing the neighbours to host more onlookers. And so the questioning began. People’s knowledge of what chickenpox is and how it presents was examined and expanded. Once this basis was established much time was spent hearing how people would respond on discovering a case. And once again the use of open questions e.g. “what would you say to someone in your community who has chickenpox”, “what if they don’t want to go to the OPD?” Eventually a community response was formulated. Not a speedy process but one which ensured everyone felt that they had an opportunity to contribute. Busy like Sunday morning March 23, 2008 Sunday morning at the Out Patient Department (OPD) is traditionally the busiest day of the week, coping with the rush after the two day weekend. Apparently people had been queuing since 4 this morning which was quite usual. I arrived after 9 and there were people everywhere. The waiting areas were extending right to the back of the clinic. The overcrowded OPD waiting room. The Rohingya women wear Burkas when they are outside of the camp and, as the majority of the waiting patients are women and their children, the waiting room is awash with black revealing small glimpses of their colourful head scarfs. The four nurses were busy assessing those in the waiting rooms and prioritising those in most urgent need of medical treatment. Next for them was a consultation with one of the doctors who invariably directed them back for treatment by the nurses. The treatment room was a constant stream of activity, suturing, dressing and tending according to the directions of the three doctors. One toddler had an anti-bacterial purple lotion applied to a bad burn down his right arm. On my journeys through the camp I’d seen a lot of the little ones with this purple dye staining parts of their body. The indigo scarf draped around this little toddler's mother was an almost identical shade. The child appeared surprisingly composed given the coverage of this fresh looking wound on his body. Others were not so contained. There was a regular stream of cries coming from the children’s visits to the treatment room. One young man came slowly and painfully hobbling out of the treatment room using a thick branch as a crutch. He has taken a month to come and seek treatment for a first degree burn on his shin because he had been working in a local town and couldn’t afford the treatment there. By the time he came to the OPD his wound had deteriorated to such an extent that his bone was now exposed. Doctor Babul explained that he needed to spend the next four weeks in Médecins Sans Frontières’s Inpatient Department (IPD) in the Nyapara refugee camp. The man was concerned about not being able to provide for his family if he was hospitalised. Emmanuel, the nursing supervisor, had an effective way of countering his very valid concerns. He asked “Have you known any of your neighbours with similar wounds?”.” Yes” the man replied. “What happened when they didn’t get treatment” asked Emmanuel. ”They died” replied the man. There was a pause. “We will treat you, we will feed you, you will not have to pay any money” When the man left Doctor Babul explained to me that around 60% of the patients from the OPD are not from the Tal camp but living in the host (local) community - some Bangladeshi and some were also Rohingya. Médecins Sans Frontières offers the only free health care to anyone in this area. Although the Rohingya are the reason Médecins Sans Frontières originally came to this area this figure really illustrates the real barriers faced by the host community in accessing health care. Lorry Crash 21 March, 2008 Friday is the start of the weekend in Bangladesh. But today turned out not to be as relaxing as the plans had sounded. The international and national staff had been talking all week about Friday’s picnic in the local national park. However the picnic involved climbing a trail to an outlook on the summit of a small mountain. This bit wasn’t so bad. And being on top was definitely the highlight, a great opportunity for me to appreciate the flatness of the land below and it’s proximity to Myanmar. It was the descent that was quite hairy, particularly because of a phone call Kolja, the German doctor, received as we were packing up the picnic, informing him of a traffic accident at Tal camp. It transpired that two people from the camp had been killed, a young child aged three and his grandmother, and four others were injured. We hurried down the mountain to the vehicle and drove to the Teknaf Ministry of Health hospital where the injured had been taken. Along the way we passed the site of the accident. One of the many colourful and overloaded brick lorries I’d seen speeding along the highway had overturned spilling its contents onto the side of the road. We all remarked at how fortunate it was that the lorry hadn’t toppled onto the other side of the camp side of the road or its impact would have been horrific. The accident scene where the woman and child were killed. We drove onto the hospital commenting on the speed of other vehicles along the way. Kolja went to track down the patients involved in the accident accompanied by a trail of curious onlookers, including hospital visitors and other patients. He eventually had to shoo them away when he did find the casualties to safeguard the patients’ privacy. Kolja referred one of the patients, who had a suspected pelvic fracture, to the Cox’s bazaar hospital, three hours north, where they would be able to get an x-ray today. I left the hospital to return to the scene of the crash. Abul, a driver who had been working with Médecins Sans Frontières since 1992, drove me and we spoke about the careless attitude of most drivers on this stretch of the road. He explained to me Médecins Sans Frontières’s 10km / hr rule around Tal and how, in an attempt to lead by example, Médecins Sans Frontières drivers will avoid letting other cars overtake whilst passing the camp. As we walked towards the accident scene there was a big commotion and the crowd who had surrounded the overturned lorry began surging towards us. Then it became clear why. Ahead of this procession, and freshly removed from the accident site, the dead woman and her little grandson were being carried passed us to their family’s home. We just happened to be standing outside of it. The crowd gathered around the house where the wailing began. MHP 20 March, 2008 Today I joined the mental health programme team as they rehearsed their new play in the Therapeutic Feeding Centre (TFC). The play is designed to address the widespread problem of domestic violence within the camp. It illustrates some positive inter-relational responses to this issue and opens the topic for community discussion. There was a hush as all three of the counsellors took the stage, a dimly lit corner of the TFC. Jamal, played the husband, Beauty took the role of the protagonist ”Yasmin”, and Hamid played herself in the role of mental health counsellor to Yasmin. Beauty, Jamal and Hamida performing a play about domestic violence. I was trying to follow what was going on in this foreign language but kept getting distracted by the audience. All of the adults, and some of the children, were riveted. But when Beauty sang she captivated the whole audience. Such a marked contrast to yesterday’s noise levels! And all the while the TFC team kept working, checking more patients in and, because no one was leaving, the room quickly became very crowded. In the end some of the audience were forced to share the stage with the counsellors. The end of the play was marked with a big round of applause and the feedback session began with the counsellors posing questions to the audience. There was a pause before the first question was shyly answered by an older woman sitting near the stage. Then came a concerted round of applause initiated by the counsellors. This worked well to warm up the audience to public speaking and soon hands were being raised to ask questions and air their opinions. The applause continued after each exchange confirming the value of every contribution. Beauty leads the applause after an audience member's contribution to the discussion. Afterwards Myabi, the MHP Coordinator, told me it had taken quite a few plays to get to this point. After the first few performances the team were met with stony silence. Understandable really given those first plays were introducing the concept of mental health, a foreign notion, to the Rohingya. The next theme was counselling and how it can help with depressive thoughts. The third theme was stress and some of the practical ways of managing it. It seemed a real shame that the only men benefitting from today’s performance were the Médecins Sans Frontières team but Myabi acknowledged that the play would be taken systematically into each section of the camp. Because of the space restrictions finding a large space within the camp was a real challenge. Previous performances have seen sixty people squeeze into a small meeting room and a record breaking session saw audience numbers hit the two hundred mark. The team regrouped in the small MHP room adjoining the TFC aglow with the success of their performances. Myabi explained that the play is one aspect of their community education, one of the four pillars supporting the programme. As a trained psychiatrist, or brain doctor as some of the community have been calling her, she is responsible for the psychiatric pillar. What I witnessed yesterday at the TFC was an example of the psychosocial pillar. The forth pillar is counselling. The counselling aspect is focused around the TFC. When a new child comes to the TFC their mother is asked if she would like to complete a short questionnaire. If the results of this assessment show that she has depression she will be visited in her home by one of the team to discuss how the counselling services may help her. This afternoon I was invited to accompany Beauty on one of her home visits. We walked through the camp to a tiny dwelling on the periphery of the camp. We were invited into the dark cramped interior by a woman with an obvious black eye and I couldn’t help but think back to the focus of the play. Beauty visits the home of a potential new client to her counselling service. Client confidentiality is taken extremely seriously by the team and Beauty stressed that personal information divulged to the counsellor by the patient could not be shared with me. For this reason I was not privy to the conversation however on our walk back to the MHP centre Beauty did confirm that this woman had agreed to be her patient. That night I marvelled at the impact this team were making on this population. Over dinner Myabi told me how a number of men had started coming to the centre having heard about the work of the team. What a huge turn around for a population that less than a year ago knew nothing about the concept of mental health. Play time at the TFC 19 March, 2008 I headed straight to the Therapeutic Feeding Centre (TFC) this morning. I had expected that the children attending the centre would be accompanied by their mothers and was surprised by the number of older women and children who took the carer’s role. A recent Médecins Sans Frontières survey of the camp’s inhabitants has found that a third of the families are female headed. This places a huge responsibility on the mother to provide for her children. She must find water, firewood and food. And because of the virtually nonexistent employment options for these women this often translates as spending the days begging in nearby villages. Seeing these grandmothers, aunties, siblings and cousins also hit home to me the importance of the extended family for this culture and the early responsibilities on the young family members. It seemed much louder than yesterday’s visit but the noise wasn’t coming from the children or their carers. In fact most of the noise was coming from bells and plastic and wood. All the kids had brightly coloured toys. Some were mesmerised by them. The attention of others was being demanded by carers rattling their toy. They were making quite a din. Today this little boy was responsible for the feeding of his brother. The Médecins Sans Frontières mental health team were scattered around the room mingling with the children and carers. Myabi, the coordinator of the team, explained that this is one of the aspects of the team’s psychosocial focus with the children and their carers. She stressed to me the importance of carer interaction when a child is being fed. Research has proven that children put on significantly more weight when they are being held and interacted with whilst being fed. So the team were spreading the message to the mothers and grandmothers, aunties and siblings. And the toys were being used to focus this engagement between the child and its carer. This little girl was enjoying her time in the weighing bucket Some of the children were having their weekly measurements taken. Some found the experience of being weighed in the pink bucket swinging from scales a real treat. Others had quite a different reaction. The child is then laid in a wooden tray to ascertain their height and finally their upper arm circumference is measured. These results combined provide an indicator of how malnourished they are. This toddler had just been registered in the red category, thus the red ankle bracelet. Sitting on the green plastic mat amongst all this racket I watched the steady flow of children being led through the room to wash their hands, pick up their packet of food, grab a beaker of water, munch away while playing with their toy and, finally, rewash their little hands. The food packet contains milk powder, sugars, vegetable fats, and the necessary nutrients, vitamins and minerals that a young child needs in an individually wrapped ration. One thing’s for sure - the kids loved it. Tal tour 18 March, 2008 First up this morning was my official briefing with fast talking Shannon the Project Coordinator. Within an hour she had given me a potted history of the project. How Médecins Sans Frontières had started working in the camp two years ago following a rapid health assessment of the camp which indicated high mortality and malnutrition levels. How the government were planning to move these refugees to a new location six km away before the monsoon started in June or July. How Médecins Sans Frontières have many concerns regarding the condition of the current Tal camp and the planned move. When we got to Tal the air seemed so thick with dust from the busy highway and the wood fires within the dwellings. The homes looked impossibly delicate, made from bamboo, plastic sheeting and flimsy garbage bags. The stench was as I had been expecting it would be considering the makeshift drainage and waste management network. As we walked the narrow alleyways of Tal we raised quite a level of curiosity and were generally warmly welcomed. Many people were engrossed in a range of activities, chopping firewood, repairing the bamboo and plastic sheeting, fetching big jugs of water. There were however quite a few looking listless and languid. This Rohingya community have had to be extremely resourceful to survive for all these years without any external aid. Shannon talking to some of the Rohingya refugees living in Tal camp. Médecins Sans Frontières has been the only organisation working in the camp and I was aware of the privilege that wearing the Médecins Sans Frontières T-shirt bestowed. Apart from the central aim of providing primary health care Médecins Sans Frontières has been advocating on behalf of this Rohingya community to bring encourage? other non-government organisations (NGOs) into the camp. The past few months have seen a couple of international NGOs initiate projects which mean they will work with this population in the near future. Shannon’s experience in the camp was a real comfort to me as I followed her wide eyed and conscious of being the new face. We finished the morning with one of Shannon’s self proclaimed “famous latrine tours”. It became clear that she has had a lot of experience in providing these sorts of tours to the government officials and NGOs that Médecins Sans Frontières is lobbying. I have been fast becoming used to the noise assault of this country but the camp seemed to be the loudest environment yet. From the children’s chorus of, “hello”, “bye bye” and “farlang” (which translates as stranger) to the constant noise of the traffic on the road. It would appear Médecins Sans Frontières cars show unusual respect in slowing down whilst passing this high density area. Nearly all of the other vehicles were speeding along, beeping their horns all the way. Shannon walking along the busy highway that runs the length of Tal camp. We had to walk along the road to access the full length of the camp and the traffic was terrifying given the lack of a footpath. This is a major hazard for the children who, with such limited space within the camp, play in the forest area across the busy road. We spent the rest of the morning visiting the Therapeutic Feeding Centre (TFC), the Mental Health Centre (MHC) and the Outpatient clinic (OPD). The TFC is a bamboo building at the edge of the camp, where under 5’s and their carers make a twice daily trip for in-centre feeding. A small office attached to the TFC is the hub of the Mental Health programme. Across the road and a few hundred meters up lies the busy outpatient clinic. These buildings mark the hub of Médecins Sans Frontières activities in the camp. Shannon introduced me to the staff and we worked out when I could meet them in the coming days to learn more about their activities.On tomorrow’s agenda is the TFC. A day amongst the toddlers, I’m looking forward to this… Day zero 17 March, 2008 So here I am in Bangladesh, after months of researching the superlative filled stats; most corrupt, most densely populated, one of the five poorest countries of the world. In the midst of this resource-poor country, on the tip of the southeast peninsula, are up to 300,000 Rohingya refugees who have fled from Myanmar. Around 10,000 of them have been surviving in the squalid conditions of the Tal makeshift camp. Médecins Sans Frontières became involved in the Tal camp in 2006 and I am here to document the project for the web in my capacity as Médecins Sans Frontières Australia web manager. I’d read accounts of their life in their homeland of Myanmar, a country which stopped recognising them as citizens in the 80s. Some had had their land and assets confiscated. Others had fled violence, arbitrary arrest and forced labour. It’s well documented by many other organisations that these people have experienced gross violations of their human rights. This morning I flew the 50 minutes from the capital city of Dhaka to the south-eastern hub of Cox’s Bazaar. I was accompanied by Myabi, who had initiated the project’s Mental Healthcare Programme. During the trip she updated me on her 9 months worth of experiences in Teknaf where the Médecins Sans Frontières team are based. I was grateful for her shared insight into the lives of these Rohingya. Sayed the Médecins Sans Frontières driver picked us up and we journeyed down the single lane windy highway passing busy rickshaw jammed villages and lots of people everywhere, walking along the road and tending the paddy fields and salt ponds. After three hours the car slowed right down as said explained we were approaching the Tal camp. And there it was, looking just like the photographs I had seen only so much busier and noisier. First view of the tal makeshift camp. There were lots of smiles and greetings called out to us. This reaction was reserved just for the Médecins Sans Frontières car and not for the vehicles hurtling towards us in the opposite direction. I wonder just what an impact Médecins Sans Frontières has had on the lives of these people to be getting this sort of welcome. One in ten of the homes in Tal camp flood daily. In monsoon season the number raises to eight out of ten. At dinner I met the international Médecins Sans Frontières team based in Teknaf. And what an international bunch they are: Shannon from Canada, Myabi from Japan, Kolja from Germany, Emmanuel from Sierra Leone and Adrien, from Democratic Republic of Congo. My African colleagues had a decade’s worth of experience working with Médecins Sans Frontières across Africa and Asia. Emmanuel and Adrien told me they had never experienced such poor conditions within a refugee camp. This thought has stayed with me - what will I be writing tomorrow night? What sights will I have witnessed, what stories will have been shared and what interactions I will be reporting on my first day in Tal?

WATER WATER EVERYWHERE...

March 25, 2008

Water is a constant issue in the camp. All year round salt water from the tidal river Naf floods at least 10% of the homes twice a day. In the rainy season 80% of the dwellings become submerged. And yet all year round the scarcity of clean drinking water is a huge problem.

Adrien, the logistician and water and sanitation (WATSAN) expert, had a meeting with some of the elders of the nearby Lada Bazaar village this morning. The meeting took place at the village school. This is one of the six local sites chosen for the construction of wells because of the proximity to the new Tal site. I joined him and the WATSAN team.

There were quite a number of local dignitaries to meet us at the school showing how important this well was to the community. After the pleasantries the Médecins Sans Frontières WATSAN team met with a couple of local labourers to map out the best place to position the well on the school grounds. A spot was chosen which would adhere to Médecins Sans Frontières guidelines, which include keeping a certain distance from latrines, and the labourers got to work.

: Adrien and village elders supervising the dig for water

Adrien explained how finding water could mean drilling forty feet, the average depth of the water table in this part of the country. And if there was no success in this position the process would have to be repeated in another spot. There were no hydrological surveys of the area so water exploration can be quite arduous.

As one of the labourers started digging a hole with a long sharp ended metal rod, I wondered just how many days it would take to find water. In no time, as we chatted with the school teachers and elders a really deep hole had appeared. The other labourer ran off with two large empty 5 litre tins attached to the ends of a branch balanced across his shoulders. He returned with water in the cans, which must have been really heavy, and began to help dig an adjoining square hole a foot deep. The water was then emptied into this square hole to form a mini reservoir. Adrien explained how it could now be used to soften the soil so they could dig deeper.

Three branches were then dug into the ground and the metal digging implement balanced across two nails which had been knocked into one of the branches. Voilà, in less than 5 mins they'd assembled a basic drilling device. We left them driving metal tubing into the deep hole and adjourned to the school for some tea.

As we left the school Adrien explained the importance of supporting this community in preparation for the relocation of the Tal camp to near their village. The WATSAN team are trying to mitigate against the increased pressure of the natural resources that this move will create. Provision of water for the host community also fulfils Médecins Sans Frontières’s principle of non-discrimination where services are available to all who need it, Rohingya and Bangladeshi alike.

: Collecting water is quite an ordeal

Chickenpox

March 24, 2008

Last night at dinner we shared our childhood chickenpox stories. Our personal horror stories certainly proved that the disease didn’t just leave physical scars. The subject had arisen when I’d asked to sit in on Emmanuel’s next training session with the Hygiene Promoters (HP) which happened to be on chickenpox.

Today I was introduced to the seven HP’s in the training room at the clinic. Shawrna was the crucial conduit, translating Emmanuel’s passionate delivery into Bengali and the HP’s responses into English.

Emmanuel's style of constant questioning ensured he had everyone’s attention. He soon filled up the white board with their responses. After reaching consensus on what chickenpox actually is he focused the HP’s on how to communicate this to the Rohingya. He was constantly reminding them “let’s keep it non-clinical” and forcing them to focus on the thought processes of this population.

At the end of the session Emmanuel requested that someone volunteer to take the chickenpox message to the camp this afternoon under his supervision. Manashi Rani, one of the most vocal participants of the training session, took up the challenge.

It just so happened that her section of the camp is at the farthest end of the camp from the clinic. So that afternoon we all set off along the busy road causing much commotion as we went. There were the usual swarm of Rohingya who seem to accompany “farlangs” (Bengali for outsiders) around the camp. As most of our chaperones were under 10 we had to be extra vigilant on their behalf and watch out for the speeding traffic.

: Community health training in Tal dwelling - Emmanuel on bottom right.

When we arrived at the house where the training session was to take place I wondered how we were all going to fit in. The word had spread so this relatively large house by camp standards, measuring approx 3 metres squared, had 10 women already gathered. As another seven of us squeezed into the home the plastic sheeting, which formed the partition walls between the homes, came into its own when it was unpinned allowing the neighbours to host more onlookers.

And so the questioning began. People’s knowledge of what chickenpox is and how it presents was examined and expanded. Once this basis was established much time was spent hearing how people would respond on discovering a case. And once again the use of open questions e.g. “what would you say to someone in your community who has chickenpox”, “what if they don’t want to go to the OPD?”

Eventually a community response was formulated. Not a speedy process but one which ensured everyone felt that they had an opportunity to contribute.

Busy like Sunday morning

March 23, 2008

Sunday morning at the Out Patient Department (OPD) is traditionally the busiest day of the week, coping with the rush after the two day weekend. Apparently people had been queuing since 4 this morning which was quite usual. I arrived after 9 and there were people everywhere. The waiting areas were extending right to the back of the clinic.

: The overcrowded OPD waiting room.

The Rohingya women wear Burkas when they are outside of the camp and, as the majority of the waiting patients are women and their children, the waiting room is awash with black revealing small glimpses of their colourful head scarfs.

The four nurses were busy assessing those in the waiting rooms and prioritising those in most urgent need of medical treatment. Next for them was a consultation with one of the doctors who invariably directed them back for treatment by the nurses.

The treatment room was a constant stream of activity, suturing, dressing and tending according to the directions of the three doctors.

One toddler had an anti-bacterial purple lotion applied to a bad burn down his right arm. On my journeys through the camp I’d seen a lot of the little ones with this purple dye staining parts of their body. The indigo scarf draped around this little toddler's mother was an almost identical shade.

The child appeared surprisingly composed given the coverage of this fresh looking wound on his body. Others were not so contained. There was a regular stream of cries coming from the children’s visits to the treatment room.

One young man came slowly and painfully hobbling out of the treatment room using a thick branch as a crutch. He has taken a month to come and seek treatment for a first degree burn on his shin because he had been working in a local town and couldn’t afford the treatment there. By the time he came to the OPD his wound had deteriorated to such an extent that his bone was now exposed. Doctor Babul explained that he needed to spend the next four weeks in Médecins Sans Frontières’s Inpatient Department (IPD) in the Nyapara refugee camp.

The man was concerned about not being able to provide for his family if he was hospitalised. Emmanuel, the nursing supervisor, had an effective way of countering his very valid concerns. He asked “Have you known any of your neighbours with similar wounds?”.” Yes” the man replied. “What happened when they didn’t get treatment” asked Emmanuel. ”They died” replied the man. There was a pause. “We will treat you, we will feed you, you will not have to pay any money”

When the man left Doctor Babul explained to me that around 60% of the patients from the OPD are not from the Tal camp but living in the host (local) community - some Bangladeshi and some were also Rohingya. Médecins Sans Frontières offers the only free health care to anyone in this area. Although the Rohingya are the reason Médecins Sans Frontières originally came to this area this figure really illustrates the real barriers faced by the host community in accessing health care.

Lorry Crash

21 March, 2008

Friday is the start of the weekend in Bangladesh. But today turned out not to be as relaxing as the plans had sounded. The international and national staff had been talking all week about Friday’s picnic in the local national park. However the picnic involved climbing a trail to an outlook on the summit of a small mountain. This bit wasn’t so bad. And being on top was definitely the highlight, a great opportunity for me to appreciate the flatness of the land below and it’s proximity to Myanmar. It was the descent that was quite hairy, particularly because of a phone call Kolja, the German doctor, received as we were packing up the picnic, informing him of a traffic accident at Tal camp. It transpired that two people from the camp had been killed, a young child aged three and his grandmother, and four others were injured. We hurried down the mountain to the vehicle and drove to the Teknaf Ministry of Health hospital where the injured had been taken. Along the way we passed the site of the accident. One of the many colourful and overloaded brick lorries I’d seen speeding along the highway had overturned spilling its contents onto the side of the road. We all remarked at how fortunate it was that the lorry hadn’t toppled onto the other side of the camp side of the road or its impact would have been horrific.

: The accident scene where the woman and child were killed.

We drove onto the hospital commenting on the speed of other vehicles along the way. Kolja went to track down the patients involved in the accident accompanied by a trail of curious onlookers, including hospital visitors and other patients. He eventually had to shoo them away when he did find the casualties to safeguard the patients’ privacy. Kolja referred one of the patients, who had a suspected pelvic fracture, to the Cox’s bazaar hospital, three hours north, where they would be able to get an x-ray today.

I left the hospital to return to the scene of the crash. Abul, a driver who had been working with Médecins Sans Frontières since 1992, drove me and we spoke about the careless attitude of most drivers on this stretch of the road. He explained to me Médecins Sans Frontières’s 10km / hr rule around Tal and how, in an attempt to lead by example, Médecins Sans Frontières drivers will avoid letting other cars overtake whilst passing the camp.

As we walked towards the accident scene there was a big commotion and the crowd who had surrounded the overturned lorry began surging towards us. Then it became clear why. Ahead of this procession, and freshly removed from the accident site, the dead woman and her little grandson were being carried passed us to their family’s home. We just happened to be standing outside of it. The crowd gathered around the house where the wailing began.

MHP

20 March, 2008

Today I joined the mental health programme team as they rehearsed their new play in the Therapeutic Feeding Centre (TFC). The play is designed to address the widespread problem of domestic violence within the camp. It illustrates some positive inter-relational responses to this issue and opens the topic for community discussion.

There was a hush as all three of the counsellors took the stage, a dimly lit corner of the TFC. Jamal, played the husband, Beauty took the role of the protagonist ”Yasmin”, and Hamid played herself in the role of mental health counsellor to Yasmin.

: Beauty, Jamal and Hamida performing a play about domestic violence.

I was trying to follow what was going on in this foreign language but kept getting distracted by the audience. All of the adults, and some of the children, were riveted. But when Beauty sang she captivated the whole audience. Such a marked contrast to yesterday’s noise levels!

And all the while the TFC team kept working, checking more patients in and, because no one was leaving, the room quickly became very crowded. In the end some of the audience were forced to share the stage with the counsellors.

The end of the play was marked with a big round of applause and the feedback session began with the counsellors posing questions to the audience. There was a pause before the first question was shyly answered by an older woman sitting near the stage. Then came a concerted round of applause initiated by the counsellors.

This worked well to warm up the audience to public speaking and soon hands were being raised to ask questions and air their opinions. The applause continued after each exchange confirming the value of every contribution.

: Beauty leads the applause after an audience member's contribution to the discussion.

Afterwards Myabi, the MHP Coordinator, told me it had taken quite a few plays to get to this point. After the first few performances the team were met with stony silence. Understandable really given those first plays were introducing the concept of mental health, a foreign notion, to the Rohingya. The next theme was counselling and how it can help with depressive thoughts. The third theme was stress and some of the practical ways of managing it.

It seemed a real shame that the only men benefitting from today’s performance were the Médecins Sans Frontières team but Myabi acknowledged that the play would be taken systematically into each section of the camp. Because of the space restrictions finding a large space within the camp was a real challenge. Previous performances have seen sixty people squeeze into a small meeting room and a record breaking session saw audience numbers hit the two hundred mark.

The team regrouped in the small MHP room adjoining the TFC aglow with the success of their performances. Myabi explained that the play is one aspect of their community education, one of the four pillars supporting the programme. As a trained psychiatrist, or brain doctor as some of the community have been calling her, she is responsible for the psychiatric pillar. What I witnessed yesterday at the TFC was an example of the psychosocial pillar. The forth pillar is counselling.

The counselling aspect is focused around the TFC. When a new child comes to the TFC their mother is asked if she would like to complete a short questionnaire. If the results of this assessment show that she has depression she will be visited in her home by one of the team to discuss how the counselling services may help her. This afternoon I was invited to accompany Beauty on one of her home visits.

We walked through the camp to a tiny dwelling on the periphery of the camp. We were invited into the dark cramped interior by a woman with an obvious black eye and I couldn’t help but think back to the focus of the play.

: Beauty visits the home of a potential new client to her counselling service.

Client confidentiality is taken extremely seriously by the team and Beauty stressed that personal information divulged to the counsellor by the patient could not be shared with me. For this reason I was not privy to the conversation however on our walk back to the MHP centre Beauty did confirm that this woman had agreed to be her patient.

That night I marvelled at the impact this team were making on this population. Over dinner Myabi told me how a number of men had started coming to the centre having heard about the work of the team. What a huge turn around for a population that less than a year ago knew nothing about the concept of mental health.

Play time at the TFC

19 March, 2008

I headed straight to the Therapeutic Feeding Centre (TFC) this morning. I had expected that the children attending the centre would be accompanied by their mothers and was surprised by the number of older women and children who took the carer’s role.

A recent Médecins Sans Frontières survey of the camp’s inhabitants has found that a third of the families are female headed. This places a huge responsibility on the mother to provide for her children. She must find water, firewood and food. And because of the virtually nonexistent employment options for these women this often translates as spending the days begging in nearby villages. Seeing these grandmothers, aunties, siblings and cousins also hit home to me the importance of the extended family for this culture and the early responsibilities on the young family members.

It seemed much louder than yesterday’s visit but the noise wasn’t coming from the children or their carers. In fact most of the noise was coming from bells and plastic and wood. All the kids had brightly coloured toys. Some were mesmerised by them. The attention of others was being demanded by carers rattling their toy. They were making quite a din.

: Today this little boy was responsible for the feeding of his brother.

The Médecins Sans Frontières mental health team were scattered around the room mingling with the children and carers. Myabi, the coordinator of the team, explained that this is one of the aspects of the team’s psychosocial focus with the children and their carers. She stressed to me the importance of carer interaction when a child is being fed. Research has proven that children put on significantly more weight when they are being held and interacted with whilst being fed. So the team were spreading the message to the mothers and grandmothers, aunties and siblings. And the toys were being used to focus this engagement between the child and its carer.

: This little girl was enjoying her time in the weighing bucket

Some of the children were having their weekly measurements taken. Some found the experience of being weighed in the pink bucket swinging from scales a real treat. Others had quite a different reaction. The child is then laid in a wooden tray to ascertain their height and finally their upper arm circumference is measured. These results combined provide an indicator of how malnourished they are.

: This toddler had just been registered in the red category, thus the red ankle bracelet.

Sitting on the green plastic mat amongst all this racket I watched the steady flow of children being led through the room to wash their hands, pick up their packet of food, grab a beaker of water, munch away while playing with their toy and, finally, rewash their little hands.

The food packet contains milk powder, sugars, vegetable fats, and the necessary nutrients, vitamins and minerals that a young child needs in an individually wrapped ration. One thing’s for sure - the kids loved it.

Tal tour

18 March, 2008

First up this morning was my official briefing with fast talking Shannon the Project Coordinator. Within an hour she had given me a potted history of the project. How Médecins Sans Frontières had started working in the camp two years ago following a rapid health assessment of the camp which indicated high mortality and malnutrition levels. How the government were planning to move these refugees to a new location six km away before the monsoon started in June or July. How Médecins Sans Frontières have many concerns regarding the condition of the current Tal camp and the planned move.

When we got to Tal the air seemed so thick with dust from the busy highway and the wood fires within the dwellings. The homes looked impossibly delicate, made from bamboo, plastic sheeting and flimsy garbage bags. The stench was as I had been expecting it would be considering the makeshift drainage and waste management network.

As we walked the narrow alleyways of Tal we raised quite a level of curiosity and were generally warmly welcomed. Many people were engrossed in a range of activities, chopping firewood, repairing the bamboo and plastic sheeting, fetching big jugs of water. There were however quite a few looking listless and languid. This Rohingya community have had to be extremely resourceful to survive for all these years without any external aid.

: Shannon talking to some of the Rohingya refugees living in Tal camp.

Médecins Sans Frontières has been the only organisation working in the camp and I was aware of the privilege that wearing the Médecins Sans Frontières T-shirt bestowed. Apart from the central aim of providing primary health care Médecins Sans Frontières has been advocating on behalf of this Rohingya community to bring encourage? other non-government organisations (NGOs) into the camp. The past few months have seen a couple of international NGOs initiate projects which mean they will work with this population in the near future.

Shannon’s experience in the camp was a real comfort to me as I followed her wide eyed and conscious of being the new face. We finished the morning with one of Shannon’s self proclaimed “famous latrine tours”. It became clear that she has had a lot of experience in providing these sorts of tours to the government officials and NGOs that Médecins Sans Frontières is lobbying.

I have been fast becoming used to the noise assault of this country but the camp seemed to be the loudest environment yet. From the children’s chorus of, “hello”, “bye bye” and “farlang” (which translates as stranger) to the constant noise of the traffic on the road. It would appear Médecins Sans Frontières cars show unusual respect in slowing down whilst passing this high density area. Nearly all of the other vehicles were speeding along, beeping their horns all the way.

: Shannon walking along the busy highway that runs the length of Tal camp.

We had to walk along the road to access the full length of the camp and the traffic was terrifying given the lack of a footpath. This is a major hazard for the children who, with such limited space within the camp, play in the forest area across the busy road.

We spent the rest of the morning visiting the Therapeutic Feeding Centre (TFC), the Mental Health Centre (MHC) and the Outpatient clinic (OPD). The TFC is a bamboo building at the edge of the camp, where under 5’s and their carers make a twice daily trip for in-centre feeding. A small office attached to the TFC is the hub of the Mental Health programme. Across the road and a few hundred meters up lies the busy outpatient clinic.

These buildings mark the hub of Médecins Sans Frontières activities in the camp. Shannon introduced me to the staff and we worked out when I could meet them in the coming days to learn more about their activities.On tomorrow’s agenda is the TFC. A day amongst the toddlers, I’m looking forward to this…

Day zero

17 March, 2008

So here I am in Bangladesh, after months of researching the superlative filled stats; most corrupt, most densely populated, one of the five poorest countries of the world.

In the midst of this resource-poor country, on the tip of the southeast peninsula, are up to 300,000 Rohingya refugees who have fled from Myanmar. Around 10,000 of them have been surviving in the squalid conditions of the Tal makeshift camp. Médecins Sans Frontières became involved in the Tal camp in 2006 and I am here to document the project for the web in my capacity as Médecins Sans Frontières Australia web manager.

I’d read accounts of their life in their homeland of Myanmar, a country which stopped recognising them as citizens in the 80s. Some had had their land and assets confiscated. Others had fled violence, arbitrary arrest and forced labour. It’s well documented by many other organisations that these people have experienced gross violations of their human rights.

This morning I flew the 50 minutes from the capital city of Dhaka to the south-eastern hub of Cox’s Bazaar. I was accompanied by Myabi, who had initiated the project’s Mental Healthcare Programme. During the trip she updated me on her 9 months worth of experiences in Teknaf where the Médecins Sans Frontières team are based. I was grateful for her shared insight into the lives of these Rohingya.

Sayed the Médecins Sans Frontières driver picked us up and we journeyed down the single lane windy highway passing busy rickshaw jammed villages and lots of people everywhere, walking along the road and tending the paddy fields and salt ponds.

After three hours the car slowed right down as said explained we were approaching the Tal camp. And there it was, looking just like the photographs I had seen only so much busier and noisier.

: First view of the tal makeshift camp.

There were lots of smiles and greetings called out to us. This reaction was reserved just for the Médecins Sans Frontières car and not for the vehicles hurtling towards us in the opposite direction. I wonder just what an impact Médecins Sans Frontières has had on the lives of these people to be getting this sort of welcome.

: One in ten of the homes in Tal camp flood daily. In monsoon season the number raises to eight out of ten.

At dinner I met the international Médecins Sans Frontières team based in Teknaf. And what an international bunch they are: Shannon from Canada, Myabi from Japan, Kolja from Germany, Emmanuel from Sierra Leone and Adrien, from Democratic Republic of Congo. My African colleagues had a decade’s worth of experience working with Médecins Sans Frontières across Africa and Asia.

Emmanuel and Adrien told me they had never experienced such poor conditions within a refugee camp. This thought has stayed with me - what will I be writing tomorrow night? What sights will I have witnessed, what stories will have been shared and what interactions I will be reporting on my first day in Tal?

'Ei je' ("Hello") from Bangladesh