Caring under pressure: health workers’ relationships and work environments in the Rohingya refugee camps, Cox’s Bazar, Bangladesh

Abstract Over 1 million Rohingya refugees fleeing genocide have left Myanmar’s Rakhine State and now live in overcrowded camps in Cox’s Bazar, Bangladesh. Like other countries hosting large populations of refugees and displaced persons, Bangladesh’s health system is already strained, with the humanitarian response now also reliant on it to meet the complex needs of refugees. Fulfilling the health system’s responsibilities and managing risks ultimately falls on frontline health workers. Drawing on qualitative research, data was collected in the Rohingya camps between 2022 and 2023 through 33 interviews and 4 data validation workshops with frontline health workers, and 13 key informant interviews with humanitarian personnel. From the perspectives of health workers and focusing on outbreak responses, we examined their everyday ‘relational work’ (unseen emotional investments and improvisations), the power dynamics of their relationships with patients, and factors associated with moral distress (being constrained from following best practices). Our findings demonstrated that health workers were continually improvising to keep care going in an overstretched system, yet felt demoralised as efforts were met with patient resistance and little observed impact. During the COVID-19 pandemic, these pressures intensified while working under strict government guidelines and with scarce resources. With pressures from NGO managers to not upset patients, in addition to receiving threats from patients if needs were not met, health workers were forced to accept professional and personal risks, which contributed to moral distress. Our results emphasise the urgent need for stronger professional support and protection for health workers, culturally informed training, and further research to improve care.