This triple disaster was Indonesian medical doctor Achmad Yusuf Toba’s first time to work with Doctors Without Borders. He talks about his field experience: 

“When I learned that they were looking for medical doctors to respond to the tragedy, I immediately volunteered myself. When I arrived in the field, I learned that we had been providing medical care for the victims of the disasters in Palu and Donggala. They have been doing it since day two of their arrival in the region. My primary duty is to treat patients using the mobile clinic. My work mostly involved trauma patients, such as the case of a woman who got burned by boiling water as she was running out of her house during the earthquake. I also saw many patients who suffered from fractures (broken bones), and wounds of different severity – from bruises, lacerations and injuries. Part of what I did was to also assess the evacuation centres or health posts that the team set up, and to do disease surveillance and individual follow-ups of patients to ensure that communicable diseases like diarrhoea, skin problems and respiratory tract infections would be prevented.” 

Elis and her family were at home when the tsunami hit the coast of Sunda Strait on that fateful day. Their home was located on the shorelines of Laba Kampong, Cigondang Village, Labuan Sub-district. They lived just next door to the home of her parents. 

When the first wave hit, Elis’ husband, Purwanto shouted a warning to Elis, and rushed to their daughter and his in-laws, who were next door, so they could seek safety. 

The strong wave, taller than a nearby power pole and about 7 to 12 meters high, destroyed their house and reduced it to rubble. Purwanto, 35 years old, got injured when his left thigh was hit by the tin roof of their house. Elis was trapped inside the house by a cupboard and desk, and the rubble that was left of their home. 

Fortunately, even injured, Purwanto was able to save Elis. Elis and Purwanto walked 2 kilometers towards the health centre in Labuan. 

Elis and her husband were treated by the Doctors Without Borders team at the Labuan health centre. “They checked my condition and that of the baby. I had bruises with some swelling almost all over my body. But thank God, my baby is okay.” 

The team attended to Elis and ensured her medical care. She stayed at the Labuan Health Centre for the next three days. Meanwhile, they referred Purwanto and Elis’ mother to the hospital in Pandeglang as their injuries were quite severe. Her father was also referred to the same hospital due to an injury on his left hand. 

Ten days after the typhoon struck, Emergency Coordinator Caroline Seguin described the huge logistical and human resources challenges of getting emergency aid and supply to where it was needed most.

“In the days since the typhoon hit, we’ve managed to bring more than 150 staff and hundreds of tonnes of supplies into the country. With so many health facilities damaged or destroyed, the healthcare needs are significant, especially since the living conditions exacerbate the risk of respiratory tract infections, pneumonia and waterborne diseases. In most areas where are working – Panay, Guiuan, Ormoc, Tacloban and Burauen – the health services have been severely disrupted and we’re focusing on restoring quality primary healthcare and hospital services. In Guiuan, a tent hospital has been put in place in the premises of the damaged reference hospital, while in Tacloban, an inflatable hospital will be set up this week and will provide all services including emergency room, inpatient department, and operating theatre. Teams will urgently set up maternity, obstetrics and gynaecology units. In such an apocalyptic situation, the need for mental health services is overwhelming. All of our teams include mental health officers or psychologists. It’s an extremely important aspect of our response, and quite straightforward to implement compared with other more logistically challenging services."

Loaded like human cargo into a wooden fishing trawler, around 500 people attempting to reach Malaysia from refugee camps in Bangladesh were starved and beaten by smugglers during a two-month voyage in 2020. All of the passengers were ethnic Rohingya from Myanmar, and most were aged between 12 and 20 though there were also some young children. Denied permission to land in Malaysia, the 400 or so survivors were eventually rescued by the Bangladeshi coastguard.

Amina*, a 14-year-old Rohingya girl from a small market town in western Myanmar, describes sitting on deck under the burning sun with hundreds of people for over two months. “We had to sit like this,” she says, hugging her knees to her chest. “People’s legs swelled and got paralysed. Some died and were thrown into the sea. We were adrift at sea with people dying every day. We feel like we’ve been taken from hell."

The refugees say they were beaten at the slightest provocation and given minimal food and water. “It was extremely hot and there was no food, no water,” says Amina. “We got one handful of dal and one capful of water per day.” Other survivors say they often received no food or water at all for days at a time. Desperately thirsty, many people resorted to drinking seawater.

The boat was denied permission to land in Malaysia, or in any other location, and eventually turned back towards Bangladesh. Some days before reaching Bangladesh, most of the smugglers abandoned the boat and its starving passengers. The Bangladeshi coastguard rescued the 400 or so remaining survivors. We sent teams of medical and mental health staff to support the rescue and provide emergency care to the emaciated survivors as they arrived back in Bangladesh. Medics stabilised those who were acutely unwell and referred some to MSF hospitals for malnutrition with severe complications and other conditions. Our mental health teams provided counselling to the survivors.

“Mostly people were stressed and really traumatised, frightened, uncertain. They were grieving for lost family members, and there were children who had lost their parents,” says Hanadi Katerji, nurse and medical team leader.

“The boat crew told us: ‘Everywhere you’re a refugee,’” says Amina. “In Myanmar you’re a refugee, in Bangladesh you’re a refugee, in the boat and in Malaysia too you’re considered a refugee. You will die wherever you go.”

In Hong Kong, we have been particularly concerned about public mental wellbeing during the coronavirus pandemic, especially amongst vulnerable groups who might have difficulty in seeking help. A survey showed that 72% of the foreign domestic helpers who responded have experienced depression-related symptoms. 47% in the survey sought help from their fellow workers in Hong Kong.

Doctors Without Borders/Médecins Sans Frontières (MSF) provided a training programme for community leaders in Hong Kong. By equipping them with the skills of active listening and psychological first aid, the aim was to empower them to better support their peers and understand their own boundaries when helping others. 

Karen Lau, Doctors Without Borders/Médecins Sans Frontières (MSF) Mental Health Supervisor, said, “There are limited resources providing care for the mental health of Hong Kong’s foreign domestic helpers. However, we identified how their unique sense of community and extended peer networks can be leveraged to foster social support and improve their understanding of mental health. This can then allow foreign domestic helpers to better safeguard themselves and others amidst challenging times.”

We also conducted COVID-19 health education activities in Hong Kong, distributing leaflets in Tagalog and Bahasa Indonesia and other languages, organising learning sessions and answering questions. An emergency medical team reached out to vulnerable populations in Hong Kong: the elderly, street cleaners, the visually impaired, the homeless people, ethnic minorities, migrants and asylum seekers. In addition to sharing health education information, a special question and answer session was allotted to respond to the most immediate concerns. 

Early in the coronavirus pandemic, panic began to spread through Indonesian communities as COVID-19 cases were reported by health authorities. Rumours, myths and fake news proliferated. Community leaders and officials were bombarded by questions from community members pleading for clear facts about COVID-19. There was too much information coming from too many sources – social media, chat groups, and news reports on TV, radio and in print. The situation intensified when Kalibata village, in Pancoran sub-district, was declared a COVID-19 red zone.

A Doctors Without Borders/Médecins Sans Frontières (MSF) team assessed the situation in Kalibata village. The team discovered that confusion and fear were widespread in South Jakarta and that it was difficult for most locals to find trusted COVID-19 information sources.

“We discovered that the local health centres, or Puskesmas, were eager for our support,” says Dr. Dirna Mayasari, deputy medical coordinator in Indonesia. The Puskesmas invited community leaders, religious leaders and those trained to train others to voice their concerns in a meeting.

“The community needed clear advice on how to protect themselves against COVID-19. But they also wanted to talk. All the information they were getting was just one-way communication,” says Mayasari. “They wanted an opportunity to ask questions, discuss their worries and clarify the best methods to guard against this new virus. They also wanted to share ways to spread information within their communities.” Therefore, we decided to bring information closer and started conducting face-to-face trainings for the heads of the households that make up the community.

COVID-19 has proven to be a challenge to healthcare systems in all sorts of contexts, but it is even more difficult in places recovering from conflict, and in densely populated urban areas. Hygiene is a concern when access to clean water is limited. Infection prevention and control is an even bigger challenge when physical distancing is nearly impossible.

In 2017, an armed group laid siege to the city of Marawi in the southern part of the Philippines. Conflict erupted between the Philippine army and the group. The siege lasted five months and forced around 370,000 locals to flee their homes. More than three years later, around 70,000 people continue to live in harsh conditions in temporary shelters, and another 50,000 are estimated to be living in other family members’ houses. After the siege, Doctors Without Borders/Médecins Sans Frontières (MSF) field staff made sure evacuees had access to free and clean water. Later, the support extended to mental health care, and went on to include support for three health centers in the area, treating non-communicable diseases, such as hypertension and diabetes, and providing free medication.

When the COVID-19 pandemic started and community quarantine was imposed, medical consultations at health facilities were suspended. The lack of access to clean water made following the recommendations to contain the spread of the virus particularly challenging. Patients suffering from non-communicable diseases, such as hypertension or diabetes, were especially vulnerable to the virus. Teams carried out home visits to ensure patients continued to receive their medication and to provide patients with a leaflet about the virus and on how to protect themselves and their families from it.

In the capital city of Manila, the slums of Tondo are particularly crowded, making home isolation almost impossible. Because of movement restrictions and closed businesses, many were also out of work. To help those in home quarantine, our teams provided over 2,000 COVID-19 hygiene kits, the content of which included disposable masks, thermometer, alcohol, hand soap and the contact card of a social worker. The teams also provided hygiene kits for their contacts, with similar items in the content. Since those in quarantine could not work, we collaborated with a local faith-based congregation, the Missionaries of Charity, to provide food packs as needed.

Manila's San Lazaro Hospital initially had two COVID-19 Intensive Care Units that could cater for ten patients each. There was also one ward with 20 beds, one adult male ward housing 20 patient beds, and one adult female ward with 20 patient beds. We boosted SLH’s COVID-19 testing, data management, and COVID-19 case management capacities with biomedical equipment, medicines, medical supplies, personal protective equipment, and training for infection prevention and control.

We provided San Lazaro Hospital with human resources support, to assist at the Departments of Laboratory and Epidemiology, in the COVID-19 wards, COVID-19 triage and the Tuberculosis ward. In addition to staff, equipment and medicine, we also supported SLH with infrastructure improvement.

Chika Suefuji, project coordinator in Marawi, talks about the challenges the community faced when community quarantine was imposed in March 2020.

"People couldn’t go to their masjid or mosque, which is one of the most important practices during Ramadan. Some were understandably upset to learn that they had to observe Ramadan differently; some questioned this decision, since only a few cases of COVID-19 infections had been reported in the area. We discussed this with the community and religious leaders, explaining how the virus spreads. They understood well and put out a statement asking everyone to follow the safety measures. This approach helped to disseminate accurate information and convinced a larger number of residents to follow the measures. Overall, everyone have respected social orders to protect their families and communities, and it has helped contain the virus in the community.”

Due to the difficult conditions brought about by the COVID-19 pandemic, many families in Tondo experienced anxiety and depression. Lyka Lucena worked as a mental health social worker, and she said, “They were worried about infecting others especially their loved ones. They were also scared of getting sick or getting COVID-19 again. A lot of patients were experiencing loneliness due to being away from their families. Many shared feelings of anger, frustration, and helplessness about their situation.”

Doctors Without Borders/Médecins Sans Frontières (MSF) teams offered remote mental health support to those in isolation at home. “We tried to help alleviate their distress by identifying and emphasising their healthy coping strategies and to establish ways of helping themselves. We also made sure to address feelings of being discriminated and stigmatised. We also encouraged patients to reconnect with their loved ones,” said Lucena.

Malaysia has a robust healthcare system, but COVID-19 shows that policies of social exclusion and limited access to health care can impact society as a whole. Though the government decided to ensure free access to Covid-19 testing for all, refugees and irregular migrants still live with a constant fear of being arrested and detained. This fear exists at home and in the street – as immigration raids are frequent- but even at health care facilities.

This is why we have been calling on the government to repeal Circular 10/ 2001, under which healthcare providers are obliged to report “illegal immigrants” (pendatang asing tanpa izin, or PATI) seeking healthcare services to the police and immigration authorities. We have also been calling for access to a subsidized health insurance and a legal status for irregular migrants in Malaysian law, which exempts them from the Immigration Act.

We are also advocating for the Malaysian government to cease targeting migrants and refugees in immigration raids, which risks further spread of COVID-19 in detention centres.

In addition to speaking out about the status of refugees and irregular migrants, in Penang we are providing COVID-19 health education in different languages, including Rohingya and Burmese, and translations in hospitals. We also conducted a COVID-19 health promotion campaign for Rohingya refugees via an online Rohingya news network.