Diphtheria Outbreak in Rohingya Refugees: What Conflict Does to Preventable Disease

The Kutupalong-Balukhali settlements in Cox’s Bazar, camps housing over 600,000 Rohingya refugees fleeing ethnic cleaning, have become incubators for a largely-eliminated disease. NPR’s Jason Beaubien reports that as of mid-January, the camps have had nearly 5,000 reported cases of diphtheria. This rapid increase from Médecins Sans Frontières’s December 12th report of 804 cases in Cox’s Bazar puts the area at the center of one of the worst diphtheria outbreaks of the past two decades.

When left untreated, diphtheria has up to a 50% mortality rate, causing airway blockage, heart failure, and lung infection. Luckily, the bacterial illness can be easily prevented through vaccination- it largely disappeared in the United States following the introduction of a vaccine in the 1920s, and incidences of new cases decreased dramatically at the beginning of the beginning of the 1980s with the WHO’s Expanded Program on Immunization increasing vaccination rates worldwide.

Diptheria global annual report / http://www.who.int/en/

The Rohingya, however, have become uniquely vulnerable to the disease in recent years. Historically, limited development and the recent movement restrictions and mass dislocation caused by the Myanmar government’s ethnic cleansing have severely reduced the Rohingya population’s access to healthcare, with the Rohingya-predominant townships of Maungdaw and Butheetaung having two physicians to serve a population of 158,000 people. The cost of these policies began to make itself apparent in 2015, when WHO data showed a sharp uptick in the number of diptheria cases in Myanmar after two decades of relatively stable rates:

Diptheria Incidence in Myanmar / http://www.who.int/immunization/monitoring_surveillance/burden/diphtheria/en/

Now, as a consequence of the prolonged attacks by the Myanmar government, the diphtheria outbreak among the Rohingya people is on track to surpass last year’s global reporting of 7,097 of diptheria cases. Moreover, between 2007 and 2016, the WHO recorded an average of 5,277.4 cases of diphtheria worldwide, and recorded an annual average of 8809.6 cases during the previous decade. This year’s outbreak alone stands to undo a generation’s worth of progress in combating an extremely preventable disease.

More than just confirming the scale of suffering inflicted upon the Rohingya, this recent outbreak demonstrates how quickly conflicts can open space for the resurgence of diseases. The people of Yemen, like the Rohingya, are currently facing a protracted conflict and huge amounts of displacement, and are suffering “the world’s worst cholera outbreak in the midst of the world’s largest humanitarian crisis” (alongside the spread of malaria and outbreak of diphtheria). The cholera outbreak in Yemen provides a sobering example of conflict interrupting preventative medical care, then restricting and politicizing the distribution of medicine to the population, until the outbreak reaches a scale that necessitates cancelling a shipment of nearly half the International Coordinating Group’s stockpile of cholera vaccines, because they would have little effect the spread of the disease.

Rohingyas near a refugee camps in Bangladesh / https://www.indiatvnews.com/news/india-bsf-sounds-alert-in-tripura-to-check-influx-of-rohingyas-407304

The refugee camps of the Rohingya are host to the same conditions that fueled the cholera outbreak in Yemen: crowding, poor sanitation, and strained medical resources (one doctor with Médecins Sans Frontières describes transforming the clinic in Balukhali from a clinic with a diphtheria isolation ward into a full-on a diphtheria treatment center). Yet there are some signs of hope in the Kutupalong-Balukhali camps that persist despite the grim conditions. First, the general population of Bangladesh has high coverage rates of the DTP3 vaccine, crucial to preventing the disease from making the leap from a community-level to a national outbreak. Perhaps more important, however, has been the unusually low mortality rates in the camps, thanks to the rapid response of international organizations able to offer early treatment to patients.

The efficacy of international organizations to respond to a disease outbreak cannot be taken for granted. Even with the U.S. State Department budgeting $6.5 Billion to support Gavi, the Vaccine Alliance, PEPFAR, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, President Trump has a history of dangerous and inexcusable support for anti-vaccination conspiracies, and continues to push a policy of withdrawal from international institutions. While the United States was able to contain the 2014 Ebola outbreak by sending American troops overseas, the next pandemic may emerge in a country far more hostile to the American military. And that is going beyond the fact that militaries just aren’t suitable for the low-profile, day-to-day work of prevention: ensuring communities have access to clean water, vaccines reach everyone, and that medicine is appropriately administered.

In the past century, humanity has made near-unimaginable gains in reigning in the deadly power of a whole host of diseases. We eradicated smallpox, a killer of uncountable millions, and are working towards beating measles, polio, and even diphtheria. But, if we neglect those living in conflict zones and the displaced, forget the people among the most vulnerable populations, the diseases will remain with us, and each generation will see a new outbreak of a disease they thought under control.

Mark Dybul, former head of the Global Fund to Fight AIDS, Tuberculosis and Malaria, remarked in an interview, “We’re on the right path with all three of these diseases, but if you get too far off that path, getting back on it is extremely difficult.” His sentiment holds just as true with diphtheria today.

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