I left Bangladesh earlier than I had anticipated to return home to my family due to the death of a loved one. There is so much work to be done but I will be followed by experienced midwives who will continue where I have left off, and I will also remain involved from afar. Our goal at Midwife Pilgrim is to not only provide direct care to the Rohingya women and children but to mentor the Bengali midwives so they will be more equipped to deal with this crisis after we are gone. As sustainable model is the only model that will work and we will do our best to prepare and support the midwives here. I thank the Hope Foundation for this immense work they have taken on and their commitment to the Rohingya women, and the UNFPA and all the other NGOs on the ground trying their best to make a difference.
I will leave you with some photos and stories from the last few days. I wish I could describe all I saw – but it is too vast and overwhelming to even begin. The suffering, the pain, the despair; but also connections, kindness, love, and laughter. The Rohingya people amaze me in their resiliency and I often found myself wondering how I would react if I were in their situation – would I have the strength and courage to go on as they do?
Photo Credit: Danielle Villasana This child was discovered when Nabiha, an MD from Toronto, went tent to tent to check on people. He was burned with the Myanmar Army burned down his house.Photo Credit: Danielle Villasana A food line in one of the camps. This shows only a tiny part of the line that seemed to stretch forever. People wait for hours, sometimes all day, in the hot sun, just for a bit of food.Photo Credit: Danielle Villasana This woman delivered in the HOPE Hospital due to complications with her labor. One of the concerns for cesarean birth with the Rohingya women is the care they will receive after – the risk of sepsis due to the unsanitary living conditions and the extreme circumstances it will take just for them to get to their tents. This woman spoke of the “Luting” Gang – not part of the military but she stated they were in conjunction with, and under orders of, the Myanmar military. They would take women and strip them in front of the villages before gang raping them. Many were forced to witness the murders of their husbands and sons first, many other woman were also killed. Another woman spoke of this and her 12 day journey, 9 months pregnant, carrying her children. Sometimes her feet were so raw and bloody she had to crawl. I heard these stories over and over and each time I was overwhelmed with grief and shocked at humanity. Photo Credit: Danielle Villasan
Photo Credit: Danielle Villasana Just a small part of another long line – this one for registration into the camps.Photo Credit: Danielle Villasana
Photo Credit: Danielle Villasana
I will leave you with this last photo which to me spoke of the strength and love of the people I saw.
I’m going to start today by describing some of the barriers and the situation here on the ground that affects the work we are doing.
The sheer scope of the situation is almost unfathomable. Looking out over the sea of tents you almost start to get a feel for how massive this is. Almost. Climbing the hill to see further I was not able to see the end of it. It was dizzying. This was at one camp of many. I am attaching a link to the weekly report so you can get a better understanding of the situation: Situation Report: Rohingya Crisis
Language barriers – the Rohingya do not speak Bengali or Burmese but their own dialect that is similar to one used in southern Bangladesh near the Myanmar border. While it is often close enough for the Bengali midwives and nurses I am working with to translate, there are some gaps at times making it difficult to provide adequate care. In addition, the nurses and midwives I am working with do speak English but not fluently and often they have a hard time understanding me. Imagine a game of telephone but with each person whispering their own words and in their own language – that is what it feels like sometimes in trying to help and instruct these women as I try to offer care and treatment. But we somehow muddle through and I hope it is enough.
Access to care – While there are many NGOs on the ground doing their best to provide care and services there are areas that are severely lacking in resources. I cannot say that any area is getting adequate services as it is impossible at this point (there are just too many people!) but I can say they are trying. The camps are so massive that the sections (or blocks as they are called) in the back away from the road tend not to have facilities in place. I did attend a meeting that discussed this issue and there are plans in place but it is a complicated endeavor and I have much respect for the players who are doing their best to get facilities and resources in place.
Fear of losing their tents – There have been cases where those seeking out care left their tent alone and it was taken by another desperate family. For those without other adult support (including women with their children whose husbands were killed or stayed behind) it is often too risky to seek out help when they need it.
Vulnerable people – We have always known that those who are most vulnerable (women, children, elderly, disabled) cannot access care as easily due to a variety of reasons. For some they are just not physically able to get to a clinic. There are workers trying to reach each family but with this many people it will take time.
Cooking – Without community cooking centers people must cook in their tents. Not only is this a fire hazard for the people, especially young children, but the smoke leads to respiratory issues and can be toxic depending on what is being burned. I have been told that there are groups working on getting better options for people, but I also have heard there is a reluctance on the Rohingya for reasons I have mentioned above and a cultural preference.
Sanitation – There are latrines but not nearly enough to meet the needs of the population. But more importantly they were set up quickly so do not have good infrastructure to support them. The implications of the human waste in the soil and washing down onto the lower levels leads us to believe it is only a matter of time until there is a outbreak of cholera or other serious diseases. I do not have a photo but will try to get one of one set up on a small ledge that leads directly to a different section of the camp.
Safe water and food – Obviously safe drinking water is imperative for the health of any community but the number of people make it almost impossible. Food problems not only include distribution and quantities, but guaranteeing adequate calories and nutritional content in addition to the cooking issues I mentioned above. As a health care provider this is one of the biggest challenges because without safe water and adequate, nutritious food you cannot be healthy and we cannot offer adequate treatment to health care problems.
Photo Credit: Danielle Villasana HOPE Clinic getting ready to open for the day
Yesterday was difficult. The heat was overbearing and the numbers of patients was astounding. The physician I was working alongside saw 129 patients before she just couldn’t do anymore! I had planned on going straight to the tents to check on the postpartum mamas and babies but I could not find a moment until my “room” was used for prayer. The long trek up the steep ill in the unbearable heat challenged me in ways physically I had not experienced in a long time.
Photo Credit: Danielle VillasanaPhoto Credit: Danielle Villasana You can see the HOPE Reproductive Health Clinic below with the gold and black plastic rooves
Before I was to leave for “home visits,” a woman came in with a crying baby who was clearly malnourished. This baby was in better health than the baby from the day before, but infants have very little reserve and their health can change quickly. The baby was 1 month old and while the mother said she was nursing some, she was feeding her rice and another food that we could not translate. We went into the corner and I watched the mama nurse, making sure there was adequate milk and the baby was nursing properly. She reported she was feeding 3 times each day as she had another baby (I am assuming a young toddler) she was nursing as well. This woman was anemic, malnourished and had no access to safe water and she is trying to feed her children the best she can. It broke my heart. The baby fed well and I asked her to please nurse the baby every 2 hours and to not feed her anything else – but I don’t know if that is possible and it is situations like this that bring me to tears.
Photo Credit: Danielle Villasana 1 month old and only being breastfed 3 times each day. She is suffering from malnutrition but is not in the severe stages yetPhoto Credit: Danielle Villasana Much happier after a good feeding
I went first to Sumana to check on her and her new daughter. Sumana looked less shell shocked but was still recovering and weak. Her baby was hungry but Sumana had not been feeding her enough. After assuring myself that they was no immediate health crisis I made sure to watch Sumana nurse her baby and tried to have the Bengali midwives I am working with instruct her in how often to feed. I know they did their best but I am not certain the message was understood.
I was able to check my other mama and baby and they were doing well. She had two other children and her mother for support. I did learn they do not have enough food and since she is weak from childbirth and her mother is elderly I do not know if they have been able to seek food out from the distributions but it is unlikely. I was able to give them the few things in my bag but obviously it is not enough and I worry for their health.
Photo Credit: Danielle Villasana
During my postpartum visits we were alerted to a delivery that had happened earlier that morning. On arriving at their tent the outside temperature must have been close to 100F – feeling even hotter due to the humidity. As I mentioned before the black plastic with the sun shining on it leads to tents that feel like ovens. There is some ventilation via the door, but it is not enough. We saw smoke billowing from the eaves of the “roof” and they had a very smokey fire going in the center. I cannot describe how unbearable it was and how clearly dangerous for a newborn baby to be in that smoke and heat. In addition they had the baby wrapped up in 2 blankets and I was truly worried for that baby’s life.
Photo Credit: Danielle VillasanaPhoto Credit: Danielle VillasanaPhoto Credit: Danielle Villasana HOPE midwives discuss smoke and heat to the mama while I check the babyPhoto Credit: Danielle Villasana
I learned that the severely malnourished infant with the cleft lip and palate never arrived at HOPE Hospital. All I can do is hope they went to another hospital to receive the care she so desperately needed.
My 3rd day in Bangladesh was spent in a meeting with the UNFPA and other health workers at the Kutupalong Camp to discuss the maternal mortalities that have occurred. Sadly we learned of another death just that morning, the third in 2 weeks, and there was an urgency to understand where the breakdown in care was occurring and how best to remedy this so it doesn’t happen again. That would be ideal but we know there will be more maternal deaths – there are too many women, not enough resources, language barriers, lack of transportation, and cultural barriers that preclude some women from seeing out care. The situation here is overwhelming and more and more I am impressed with the work of those on the ground who are trying to make a difference. They are. But it is not enough.
Children at Kutapolong Camp. This camp has been in Bangladesh since 1992 and usually has 32,000 refugees. Since August 25, 2017 reports say it has expanded three-fold.
Day 4 was back in Balakhali camp. I had made a plan to go immediately to check on the postpartum mother and baby – I was anxious to see them as I didn’t get to the camps the day before. On arrival I was told there was a “delivery happening, so please if you can get there quickly.” Up the steep hill in the heat – and for those who know me – it wasn’t easy but I did it! And then we couldn’t find the right tent. A lovely woman saw me hot and out of breath and sent a stool our for me. Those are the times I feel so pathetic!
Finally we made it and there was a young first time mother, Sumana, giving birth with 5 women surrounding her. She looked terrified and exhausted and the bit of information I could get was that she had started pushing soon before I arrived. The woman sitting next to me, Rozario, was a traditional birth attendant from Myanmar and had been at the births of each women in the room and their children. She had gloves on and together we helped Sumana bring her baby girl into the world. While we could not share a spoken language, Rozario and I found ways to discuss the case, how best to help Sumana, and it felt like we had always worked together we were so in sync. I was impressed with her skill and knowledge and together we were able to offer the Bengali midwives some new skills. The birth went well without any complications. The baby nursed well and was perfect in every way – but so tiny!
These women are malnourished and their infants are too. During labor I wanted Sumana to have some nutrients but there was nothing to be found. I was so thankful I had packed some granola bars in my bag and she ate like someone who was desperate for food. She was. She ate them all and after her birth she ate the bread and peanut butter I had packed too. I wish I had brought more. Tomorrow I will make sure to pack even more food just in case.
Sumana is being held by her mother, Rozario is next to me
Me making a moosh face at this perfect new beingSumana and her baby, Sumana’s mother, me, Rozario
Fortunately next door was the postpartum mama and her baby that I was so anxious to check on. They were doing really well! That was a relief.
Back at the clinic things got busy. I am getting a lot of women thinking they are pregnant but none were. Their missed cycles are likely due to stress and malnutrition. Some left in relief as they did not want a child, others were disappointed. There were many prenatal visits and some primary care. One elderly woman was short of breath and clearly anxious – she was struggling and it was frightening to her. I referred her to the nearest hospital that had a nebulizer.
One woman arrived with a 15 day old infant that was clearly starving. The child had a cleft lip and palate and showed signs of severe starvation. You could obviously see just by glancing that this baby was in a desperate state of health and I immediately referred her to the Hope hospital for care. Her mother clearly loved her and was doing her best, but the baby could not nurse and the mother was dripping drops of cow’s milk into her and water when there was none.
The 14 year old I mentioned in my last post returned hoping I had good news regarding terminating this pregnancy. I didn’t but I will continue to try. I was able to finish her antibiotic proplylaxis but that was all. She told me more of her story, how she was raped by 4 men in uniform until she passed out. She told me she could marry but not if she had this baby and she was desperate to find a way to end the pregnancy. I was terrified she will try to do it herself and explained to her that she musn’t do anything rash as she could die. She then told me her father had beaten her for coming to the clinic and asking for help. They blame her for being pregnant. I was able to get her referred to a women safe space, but she was afraid. She agreed to look at it and see if she would like it but she wanted to come back and get her father’s permission. I hope he gives it to her. If not, I hope she will go anyway as there she will be safe. I promised her if she went I would check in on her so I hope to have some good news, if there is any glimmer of hope with her situation, soon.
A tom-tom which is used to transfer people to other higher level clinics if their needs are greater than we can provide. There are ambulances to take critical patients to the hospital.
If I struggled to find the words to describe yesterday then today should be silent. I am physically and emotionally spent. I will start at the end of the day and share the stories of 3 cases of rape. Ironically I arrived to the hotel to find this article in my message box from the Reproductive Health Coordinator for the UNFPA: Rohingya women facing violence, by military and inside camps (Please note this is reporting on Myanmar not Bangladesh)
The first woman to arrive reporting sexual assault was young with a toddler in tow. One of the concerns we have is ensuring all victims of sexual assault are given treatment to prevent sexually transmitted infections. However, we were quickly running out of the necessary medications and have to adjust if a woman was pregnant or not. This woman was gang raped on September 8th and fled with her young son on the 10th. She showed me the scars on her legs from where they had tortured her. She is not pregnant and extremely relieved and we treated her, referred her to counseling and support that is set up for gender based violence crimes and sent her on her way. She, like many of the women I described yesterday, looked worn out and like she had given up on life. Her affect was very flat and she took no interest in anything around her.
The second woman to arrive – I need to stop for a moment. It is here that my tears start to fall in earnest. I could not cry today – it was far to busy as the women just kept coming in and she clearly needed my support and strength not my sorrow, though I am sure she could feel my compassion for what she endured. She too was blank – and with good reason. She is 14 years old and 4 months ago was raped by four members of the Burmese Army. Now she is pregnant and seeking an abortion but is too far along for us to help her. She does not want this baby, her family does not want this baby and her family does not want her – though she still lives with them. My heart breaks for this young girl, only a couple years older than my 3rd son and looking much younger. “She is just a baby herself!” I want to scream in anger at the world which seems so cruel at times. My heart also breaks for this infant who will be born into such despair.
The last woman to arrive who was raped was not shut down. She is the one who I have the most hope for and yet her story is the most tragic. Almost 4 months ago the Burmese Army broke into her home, held her down, and made her witness them slicing her husband’s and eldest son’s throat. Then they each took turns raping her until she was given up for dead. She too got pregnant but fortunately, and yes, I agree with her that it is fortunate, she lost that pregnancy. She arrived today because she was having complications from the miscarriage and as she told her story she wailed with grief and there was nothing I could do to take that pain away.
There is much more to tell about this day – the impromptu meeting with the Brigadier Commander and then another meeting at the barracks with the Major while one of the docs who was there was speaking with the General about the needs HOPE has and how can the military help. I could tell you about how wonderful it is to see such a response from the Bengali Government to aid these people instead of shutting the doors as so many wealthier countries do. I could also tell you I had a cup of real tea – caffeine and all – and it was amazing with the sugar and lemon and ginger.
I could share how it was even hotter than yesterday, so hot I was literally drenched in sweat. Too hot to eat, too hot to move.
I could share of the warm smiles and the Bengali language lessons the Hope team was trying to give me (and laughing at me no doubt).
I could share more stories of the women I saw and how it seems there is always suffering, somehow.
But I will share the beginning of the day. When there was hope and joy. I had a feeling – my midwife intuition – that as we were heading to the camp we were missing a birth. Sure enough when we arrived we were asked to go to a woman who had given birth less than an hour before and was bleeding. We ran up the hill and back into the endless sea of tents to find this woman nursing one of the most beautiful babies I had ever seen. The hot sun on the black plastic made the tent unbearable to be in and to make it worse they had a fire going to burn the placenta and the bloody clothes making it filled with smoke. I had them put it out immediately as the baby would not tolerate that for long (nor would I). It was so hot in the tent you could almost not breathe. Sure enough the mama had some issues but we were able to resolve them quickly and she did much better. I am truly grateful we were there and shudder to think of the what ifs?. The baby was perfect and healthy.
In thinking about this day I am at a loss for words but will do my best to describe my experience. As I sit here in my hotel room listening to the call to prayer outside ringing through the sky I am overwhelmed with emotions and realize I am too hot and exhausted and jet lagged to be able to share this journey in a way that will truly express this day.
I want to begin by saying how astounded and relieved I am that women’s health is a focus in the camps and within the communities. I have never witnessed such a dedication to reproductive health anywhere we have worked with refugee populations. It offers me hope in seeing how it should be done instead of all the frustration and anger I have often felt in working so hard to even get one NGO, one government official to realize how vital this is and to take steps to ensure it is readily available. I am gratefully overjoyed.
I am working with the Hope Foundation for Women & Children in Bangladesh (www.hopeforbangladesh.org) in conjunction with the UNFPA. Currently Hope is providing mobile medical care cycling providers through the various camps. In addition they run a hospital for women and children which has emergency facilities improving the health and saving the lives of members of their community. There is one other NGO providing reproductive health services. For now Hope has clinic hours during the days and referring women to the “fixed” clinics that are spread near each of the camps for after hours. The biggest issue is alerting women to the existence of these clinics and of course ensuring they have the means to get there.
During the day Hope also has teams at each camp walking around seeking out those who may have health issues who cannot make it to the clinic. They are armed with a stretcher and at the bottom of the hill at each road are tom-toms to transport women to the hospital if their condition is deemed too high risk to birth in the camp. I was at Balukhali camp today and was told they have had 8 deliveries there in the last 2 weeks. There is also groundwork being done for a field hospital to be built in the location the Balukhali Camp clinic is now. That will enable more access to critical care services and provide 24/7 care to the women in this camp.
Reproductive Health Clinic at Bulakhali Camp
Full access is a concern of mine as the women I cared for today were in poor health: underweight, malnourished, anemic, suffering emotional trauma and experiencing the stressors of living in crowded camp conditions with limited food and safe drinking water. That is the perfect set up for complications during pregnancy and birth and I worry that without a skilled midwife present there will be many maternal deaths. Tragically just this morning there was a maternal death in a camp nearby – the second in 2 weeks. The clinic was not run by Hope and we are still waiting to hear the details so we can train the midwives and clinicians better – but it was news that brought me to tears.
The exam room the midwives use is a corner in the clinic cordoned off with plastic and a drape for a door. The exam table is a sleeping bag like pad on the dusty dirt floor. It is very small and difficult to fit us all in but it works and I am grateful the women have a private place to go. Many women come in wearing niqab (not to be confused with burqah though that is what it is called here) and remove their head dressing so the first time I see their faces is in the room.
I worked with a Bangladeshi midwife, Sharifa, who was very sweet and while new to this calling was confident and excited to learn anything I could share. It was she who welcomed all 8 babies into this camp as she is there every day.
Sharifa learning to use a doppler for the first time and practicing her palpation skills
I can’t describe the blank faces of many of the women I cared for today. It was like they were gone – just going through the motions of existing. I heard one tale of a woman who was due any day and arrived last week – she had lost her husband and her young son. Another woman reported that she just arrived and had traveled 5 days without food but didn’t care because her infant was forcefully taken from her ams and killed in front of her. Story after story after story. It felt as if the room was filled with scars, emotional and physical, scars that may never heal.
But there was occasionally a glimmer of joy too. Many women had never had a doppler used in their care (they are not practical due to the expense and hardship of getting batteries and the humidity shortens the working span of the equipment). In fact, Sharifa the midwife I am working with had never even seen a doppler before. For a few women, hearing their baby’s heartbeat was a gift and they smiled for the first time or giggled. Those smiles refreshed me and helped me to not feel the weight of all I was witnessing and hearing.
The camps themselves were bleak places and the heat and dust mixed with the deep mud made them only more depressing. We traveled past several to get to our location. In one camp we passed there strung a long line of people almost 1 km long in line for food and supplies. I dared to hope there would be enough for all. I can’t imagine what these people are going through. I don’t want to – it is too frightening a thought. Yet here they are and this is real.
Balukhali Camp was no different. It went on and on over the hills, trees having been cut down to make room for the waves of people who arrived almost overnight – and keep coming. I could not see the end it went so far. I shudder to think of what will happen when the rains do pour down and how their shelters would be washed away in the mud. But for now this is the best anyone could manage. And like all places that become “home” there was a sense of community and once in a while there would be a child’s laughter ringing out. I have never done more important work in my life.
My 3rd day in Bangladesh was spent in a meeting with the UNFPA and other health workers at the Kutupalong Camp to discuss the maternal mortalities that have occurred. Sadly we learned of another death just that morning, the third in 2 weeks, and there was an urgency to understand where the breakdown in care was occurring and how best to remedy this so it doesn’t happen again. That would be ideal but we know there will be more maternal deaths – there are too many women, not enough resources, language barriers, lack of transportation, and cultural barriers that preclude some women from seeing out care. The situation here is overwhelming and more and more I am impressed with the work of those on the ground who are trying to make a difference. They are. But it is not enough.
Midwife Pilgrim Bangladesh 