Near to the border of Myanmar (Burma), Rakhine Muslims (usually called Rohingya) are struggling to survive. Denied citizenship in Myanmar, most of them fled harassment to locate themselves in terrible conditions in Bangladesh with poor access to health care services and inadequate protection (MSF, 2010). In 1992, more than 250,000 Rohingya Muslims from Burma were compelled to enter Bangladesh by the armed forces of Burma in a violent movement of ethnic cleansing of Muslims. Today, about 26,000 Rohingya live in Kutupalong and Nayapara camps in Cox's Bazaar district and about 100,000 unregistered refugees live along the border with Burma (HRW, 2007).
The Rohingya refugees in Bangladesh are treated as illegal migrants by the Bangladesh government (RW, 2010). The Rohingya Refugees who are staying in Bangladesh face a high risk of ill-treatment. According to Human Rights Watch (2007), they are facing inadequate humanitarian help by the Bangladesh Government which puts in danger and forces many of the refugees to ask shelter in nearby countries. Abuses, sexual violence against women by Bangladesh law enforcement agencies are also reported around Rohingya refugee camps. In Nayapara and Kutupalong, they are normally punished when they search for food outside the camp. The authorities even refuse to allow stable structures to be made in the camps. For example, children are not getting access to education. The authorities are also limiting the provision of health services and access of Rohingya refugees to medicines and international aid agencies, for example, UNHCR and MSF. The authorities prevent them from instituting programs which could offer regular services (HRW, 2007). At present Bangladeshi authorities have increased their persecution of the refugees and are obstructing the activities of the international aid agencies. More than 2,200 refugees have been returned to Myanmar against their will by the police force of Bangladesh and thousands of others have become isolated in makeshift camps in poor sanitary conditions (BG, 2010).
At present, the Rohingya refugees live in poor and unhealthy conditions and they are not permitted to leave the camp freely or to work. They live in overcrowded places with inadequate water, poor shelter and inadequate educational opportunities. Most of the Rohingya suffer from malnutrition in part due to inadequate food supplies. As a result, chronic malnutrition is one of the major health problems among 58% of the refugee children. This malnutrition exposes the children to diseases and slows down mental and physical growth (MSF, 2002). About 20% of Rohingya Muslim children have acute malnutrition in unofficial refugee camps because of inadequate food aid and health care services. The researchers of Physicians for Human Rights found that 18% of refugee children under the age of 5 had symptoms of acute malnutrition and 55% had experienced with diarrhoea in the last 30 days due to the squalid conditions of the camps (BG, 2010).
OVERVIEW OF THE HUMANITARIAN ORGANIZATION: MEDECINS SANS FRONTIERES (MSF)
Medecins Sans Frontieres (MSF) is the only international agency that is working with Rohingya refugees in the Kutupalong makeshift camp (BBC, 2009). MSF is tremendously concerned about the humanitarian issue in this camp where the number of unregistered refugees is increasing at alarming rate (RW, 2010).
MSF started working in Bangladesh in 1985. In 2008, MSF started to provide healthcare services to the Rohingya refugees in Kutupalong, estimated at more than 7500, and also to the people in the adjacent communities. Their health staff regularly provides treatment for diarrhoea, skin infections and RTIs because of their dirty living conditions. MSF also integrated different programme and projects for the Rohingya refugees, for, example, (i) a therapeutic feeding programme for seriously malnourished children, (ii) a mental health programme, and (iii) projects for the improvement of supplies of safe drinking water and sanitation in the camps (MSF, 2010).
Food insecurity was also a massive problem among the population in 2008. In reply to the high levels of food insecurity and frequency of acute malnutrition among the children under five, MSF established an emergency nutritional intervention programme in the Sajek Union area of Chittagong Hill Tracts. The aim of the intervention was to help the children who were malnourished. They also included a mobile feeding programme and an inpatient centre for the treatment of children who required quicker medical treatment (MSF, 2010). Along with the nutritional programme by MSF, a basic health clinic and 8 health outposts were set up for laboratory tests of diseases like malaria (MSF, 2010).
EXAMINATION OF ALTERNATIVE APPROACHES THAT COULD BE CONSIDERED
'Poor nutrition leads to ill health and ill health contributes to further deterioration in nutritional status. These effects are most dramatically observed in infants and young children, who bear the brunt of the onset of malnutrition and suffer the highest risk of disability and death associated with it' (WHO, 2010). The different types of malnutrition are shown in the following table-I:
Severe acute malnutrition (SAM)
Severe chronic malnutrition (SCM)
Moderate acute malnutrition
Moderate chronic malnutrition:
'Defined by a very low weight for height (below -3z scores of the median WHO growth standards), by visible severe wasting, or by the presence of nutritional oedema' (WHO, 2010).
'Calculated with the Z-score defined as a height-for-age index less than -3 standard deviations from the mean weight of a reference population of children of the same height and/or having oedema' (CEDAT, 2010).
'Calculated with the Z-score is defined as a weight-for-height (wasting) index between -2 and -3 standard deviations from the mean weight of the reference distribution for children of the same height and/or having oedema' (CEDAT, 2010).
'Calculated with the Z-score defined as a height-for-age (stunting) index between -2 and -3 standard deviations from the mean weight of a reference population of children of the same height and/or having oedema'(CEDAT, 2010).
Complex emergencies are often characterized by a high prevalence of acute malnutrition. The underlying causes of malnutrition are given in the figure-I. A range of combined strategies is required to protect, promote and support nutrition. Despite the existence of proven interventions the prevalence of acute malnutrition has remained high in complex emergencies during the last decade (Young et al., 2004).
Figure-I: Underlying causes of malnutrition
In order to meet urgent basic food needs and nutritional demands among severely acute malnourished Rohingya children, the following approaches could be considered:
Lipid based nutrient supplements (LNS) programme for malnourished children
A recent study focuses on the potential role of lipid-based nutrient supplements to meet the nutritional demands and to prevent malnutrition in emergency affected populations. The term 'lipid-based nutrient supplements (LNS)' refers to a combination of fortified, lipid based products, and Ready to Use Therapeutic Foods (RUFT). Recent research on smaller doses of other kinds of lipid-based nutrient supplements for prevention of malnutrition has raised interest in their effective use in emergencies to ensure a more nutritionally adequate ration for infants and children between 6 and 24 months of age, pregnant and lactating women (PLW) (Chaparro and Dewey, 2010).
General food distribution programme (Food-based programme)
The general food ration normally consists of dry cereals, pulses, vegetable oil and salt and blended food. The average minimum requirement for a people is 2100 kcal/person/day which serves as an initial planning outline for general rations. Some populations, like refugees and IDPs, might be completely dependent on food aid (Young et al., 2004).
Supplementary feeding programme
The objective of the supplementary feeding programme is to reduce the prevalence of moderate malnutrition and associated mortality in malnourished children. It consists of fortified food mixed with oil. The supplement of 500-1200 kcal/day is given in the form of a dry take-home premix which is usually more effective than wet feeding on site. The supplementary feeding programme gives greater coverage, increases the proportion of children who recover, and reduces the numbers of defaulters (Young et al., 2004).
Food fortification programme to malnourished children to improve their nutritional status
It is an economic and efficient way of providing micronutrients. 'The policy of the World Food Programme and major food donors is that all oil, salt, and blended should be fortified with micronutrients either singly (iodine in salt and vitamin-A in oil) or in combination' (Young et al., 2004). In case of emergency settings, fortified food seems to be an appropriate supplementary food for short-term interventions, having a quick impact on malnourished children (Kopplow, 2003).
Vitamin-A (Vit-A) supplementation programme
The refugees face high risk of clinically significant Vit-A deficiency for some reasons. For example, in nutritional emergencies, they are deprived of even their normal food supply and the relief rations given to them may be poor in Vit-A contents. Vitamin-A supplementation is an early and vital part of nutritional support given by the relief agencies to stop unnecessary morbidity and mortality. It should be a standard component of the maternal and child health care given to the affected to people until sufficiency of dietary vitamin-A has been evidently recognized (Nieburg, 1988). In order to avoid vitamin-A deficiency and to decrease the risk of mortality and eye diseases among the children aged 6 to 59 months, it is standard practice in emergencies to give vitamin-A supplementation every 4-6 months. This supplementation is often provided in conjugation with measles or other vaccination campaigns (Young et al., 2004).
RECOMMENDED APPROACH
Why Lipid based nutrient supplements (LNS) programme for malnourished Rohingya children in makeshift camp in Bangladesh
In emergency settings, general food distributions (GFD) are seen as providing general food support to the affected population. GFD rations frequently do not meet micronutrient requirements for all age groups. The standard GFD ration developed and delivered-usually consisting of a grain, pulse, vegetable oil (generally fortified with vitamin A), a fortified-blended food (FBF), sugar and/or salt-is inadequate nutritionally, particularly in the case of micronutrients, for many population subgroups with higher nutritional requirements, including infants, young children, and pregnant and lactating women (PLW) (Camila and Kathryn, 2009). A working logistics and distribution system and targeting are required for effective distribution of general food rations. When food-based programme is not practical, supplementation approach might be important to control micronutrient insufficiency disease epidemic in the short time (Young et al., 2004). The effectiveness of supplementary feeding programme has been challenged. Access to the central food distribution site, ensuring security, and the quality of care being offered affect the coverage in supplementary feeding programme (Vautier et al., 1999). Humanitarian organizations face operational challenges during implementation of therapeutic feeding programmes (Collins, 2001), including the absence of trained staff and the high establishment costs and the costs of drugs and specialized foods (Ashworth, 1997). Poor accessibility and low coverage are also the other limitations in therapeutic feeding programme (Salama et al., 2001).
Nutrition interventions have been mainly limited to selective feeding programs (i.e., therapeutic and supplementary feeding), which are used to rehabilitate malnourished children. In some cases, micronutrient interventions (such as provision of single- or multi-micronutrient tablets or powders) which aim to prevent and/or correct particular micronutrient deficiencies are also employed; however, there is limited experience with these interventions in emergency settings. Micronutrient interventions have been recognized as important for meeting the micronutrient needs of particular groups who may not be able to reach their requirements through the food commodities provided in the GFD ration alone.
PROPOSAL OF PRACTICAL STEPS FOR IMPLEMENTING THE POLICY IN PRACTICE
CONCLUSION
A violent attack on unregistered refugees in Bangladesh is pushing humanitarian conditions to the edge in the makeshift camp for them and aid workers. They get no help other than nutritional, mental health, and water and sanitation from Action Contre la Faim (ACF) and medical services from MSF-making food a major issue (RW, 2010). As the harassment of the refugees continues and a humanitarian crisis increases, it is important that the Bangladeshi Government take steps immediately to prevent the violence and give protection to these highly vulnerable refugees. In addition, Bangladesh Government must stop the tendency of pushing the unregistered refugees back to Myanmar in contravention of international humanitarian law. Moreover, the absence of a comprehensive UN policy to prevent the crisis has left a huge number of highly vulnerable Rohingya at risk. Regional solutions are also required to the situation of the stateless and unprotected Rohingya and the international community must help the Government of Bangladesh and UNHCR to take up measures to assure the unregistered Rohingya's permanent dignity and safety while they stay in Bangladesh (MSF, 2010b).
