Dispatch #2 from Kutupalong

It has been a successful whirlwind jumping headfirst into work in the refugee camp and I want to share some of my initial impressions.

1) The scale of the Kutupalong refugee camp is overwhelming

2) So is the level of development

3) The medical problems are real but ... many are related to social stressors

1 - The refugee camp is massive. We are on a hilltop near the edge of sectors 4 and 17 overlooking the sector 4 expansion. The original refugee camp land was reportedly government owned national forest land that used to host monkees, herds of Asian elephants, and lots of other wildlife. As the refugee population has grown, the impenetrable jungle-clad steep hills are clear-cut, the animals have been pushed out (though many refugees are still scared of an elephant possibly wandering into camp), and ordered chaos emerges. From our clinic, we can see a new camp sector being built with right-angled rows of houses, hundreds of refugee workers wearing neon orange vests filling sandbags to reinforce hillsides and roadways, and occasional heavy machinery moving mounds of earth. Beyond this is the jungle. Looking in all other directions is the camp. A typical house/structure has a bamboo frame, walls and roof lined with heavy-duty UNHCR plastic tarps and dirt floors. Packed together, these houses fill the landscape for as far as the eye can see, climbing up and down the steep hillsides, punctuated by staircases going up and down the hillsides and bamboo bridges over the ravines. And constant movement. Not masses of people but constant movement. If you could imagine a live-action Where's Waldo picture, that's what it seems like.

2 - The level of development and organization within the camp is very impressive. The structures are not meant to be and do not feel permanent. Same for any of the roads, plumbing, irrigation, etc. But it all feels remarkably functional. In two words, practically modular. Roads are paved with bricks then covered in dirt. Hillsides are reinforced with sandbags. Staircases are staked out with bamboo then the stairs themselves are made of sandbags that have now been packed down into clay. Not permanent but extremely functional. From afar it looks like a giant Lego-land if your pieces are made of plastic tarps, bamboo, clay, sandbags, and occasional patches of jungle and banana trees. Engineers from UNHCR (or some other UN-affiliated agency) have surveyed the camp and staked out areas/houses that are landslide prone and others that are in flood zones. To called the older sections of the camp "planned" is a misnomer but it's a lot less of a hodgepodge than many other cities I've visited in places like Ethiopia or Guatemala. 

3 - All of the medical problems I see are "real" in the sense that people are feeling the symptoms they're complaining of. However, many of these problems don't need or can't be fixed by a doctor and are directly related to the refugee's living conditions and circumstances. Here are the most common chief complaints: General weakness and feeling tired, back pain (either upper back across the shoulders or lower back), stomach burning. When asked how long it has been going on, most people say somewhere between 1-5 years. Frequently the duration corresponds with their arrival in the camp. Living in a refugee camp must be unspeakably difficult - long lines for food that's rationed once a month and then you have to carry a heavy sack of rice and a jar of oil for ten minutes to two hours depending on where you live. Sleeping on the ground in bamboo huts that probably leak during the monsoon season with mosquitos constantly eating to their hearts' delight. Steep hills that make a quarter mile walk take twenty minutes. None of this to mention the psychological trauma of being forced from your home under the threat of violence by your own government that prefers you don't exist at all. So yeah, I understand why many have weakness, fatigue, and aches. Unfortunately, there isn't much western medicine can do to help in an outpatient medical clinic setting. They get tylenol and medicine for acid reflux but I think we both know that it's merely a bandaid on a deep wound that won't hurt but also probably won't help. One of the other docs volunteering with us is a certified acupuncturist and so I've been referring a bunch of vague ache pains his way. The patients seem to be pretty happy and if it helps, I'm all for it. (Side thought: in all fairness, as an ER doc I feel well prepared to deal with this because many of the patients I see daily in my Atlanta ER come with similarly vague complaints that I can't fix that are a product of living on the street or struggling to pay monthly bills while on medicaid and food stamps, and the psychological trauma of being poor in the US. Not trying to equate homelessness in the US and refugees in Bangladesh but social and psychological stressors frequently cause people to turn to a doctor for help when unfortunately there's no pharmaceutical treatment that can fix their problem).

Now before you think it's only vague complaints, I have seen some very interesting diseases (dermatologist friends be on the lookout for texts of weird rashes) and some people who can be helped by a doctor. Asthma, COPD, diabetes. Some serious infections that need IV antibiotics. A few cases of diarrhea and severe dehydration. A handful of broken bones and cuts that need stitches. My ultrasound skills have come in handy and yesterday I sent a guy to another hospital in the camp that had surgery services because I think he likely had a blockage in his intestines that would need surgery.

Those are some of my initial impressions from the camp. Please ask questions in the comments and I'll answer in future posts. Stay tuned for upcoming posts on the medical clinic itself and the camp's medical infrastructure, the refugee industrial complex (a deep rabbit hole that I'm just starting to scratch the surface of), and what comes next for the refugees. I'm also posting some pics on Instagram (@sarimnotsorry).

And Happy Hannukah!