COVID-19 Webinar 12: Far from home- MHPSS for refugees, migrants and asylum seekers
The Lancet Psychiatry, Mental Health Innovation Network, MHPSS.net and United for Global Mental Health organises a series of weekly webinars designed to provide policy makers and the wider health community with the latest evidence on the impact of COVID-19 on mental health and how to address it.
Chair: Guglielmo Schininà (Head of Mental Health, Psychosocial Response and Intercultural Communication Section at the IOM)
Panelists:
Peter Ventevogel (Senior MHPSS specialist, UNHCR)
Theresa Ombalo (Coordinator of the Interagency MHPSS Reference Group in Ethiopia, WHO)
Rama Shyam (Programme Director, Empowerment, Health & Sexuality of Adolescents at SNEHA, a Mumbai-based NGO)
Lynne Jones, OBE (Independent Mental Health Expert & Activist)
Summary of Key Messages
• Peter Ventevogel (UNHCR): It is key to integrate MHPSS in all aspects of humanitarian work, and train all those workers, who provide assistance at the times of COVID, from doctors to shopkeepers, from law enforcement agents to priests in basic psychosocial skills.
• Theresa Ombalo: In Ethiopia, the psychosocial challenges of returning migrants extend beyond the experience of the quarantine centers where they need to be hosted upon arrival. Their reintegration back home, unexpected and unplanned is equally challenging. For this reason the wide Ethiopian network of Healthcare Extension Workers is being trained to support people who need mental health care in the community.
• Rama Shyam: As a means of state policy, we need more investment at the primary care level of MHPSS. We should build capacities of frontline and community workers. We must treat mental health support as an issue of social justice, not just clinical intervention.
• Lynne Jones: It’s not possible to have good mental health if your basic needs aren’t catered for, or if you are not secure. We need to address basic needs of migrants, and stop their discriminatory treatment. The most important solution is political… We need to lobby politicians to accept refugees into European countries.
• Guglielmo Schininà: There is no mental health without rights, and no mental health without humanity. This is true for everyone, and especially for migrants at a time when the migration discourse is so politicised. Unfortunately, the worst may still be to come, due to increased xenophobia and the fear of the “other” that the pandemic may unleash.
Record of the Meeting
Ananda Galappatti (MHPSS.net):
This webinar is being recorded.
It has been very meaningful for us to help to convene this series of webinars, that has been valuable to so many people. This webinar will focus on vulnerable people and refugees, but we will be discussing issues that will resonate with the wider public as well.
Guglielmo Schininà (IOM):
These have been troubling times, psychologically, for most of us. Being isolated, having to manage one’s most important relationships remotely, fearing to lose one’s job while not being sure about social security, having to adapt to a totally new way of life very rapidly, not being able to understand which information provided by the media is reliable or not, being perceived as a possible threat by people around you, are all distressing experiences.
These experiences are common to many migrants worldwide in their everyday life, they were so before, and probably will be so after, the pandemic.
However, while this should make the psychological experiences of migrants more relatable to all of us, it does not make the psychological experience of COVID-19 any easier for migrants. Even today, even in the most developed countries, migrants do not enjoy equal access to mental health care, or have an access that is dependent on their legal status.
Migrants are more likely to live in precarious housing, and have precarious working conditions. They have bleaker economic prospects, and with closure of borders it has become more difficult for them to go back home, if they wish. At the other extreme, in some situations they are forcibly and abruptly repatriated. They are even farther from loved ones and more exposed to media disinformation in languages they may not fully master.
If we consider a migrant anyone who has moved from their habitual place of residence to another, for whatever reason, irrespective of legal status, then we are talking about an estimated 1 billion people in the world, a multitude of populations, situations, contexts, legal definitions that would be impossible to sum up in one discussion.
We will therefore today discuss the psychosocial needs and resources of 4 specific categories of migrants.
Peter Ventevogel will focus on those who are forcibly displaced: internally or internationally, as asylum seekers and refugees. There are 80 million such people globally.
Teresa Ombalo will focus on economic migrants who are returning back home, forcibly or voluntarily because of the pandemic.
Rama Shyam will bring the perspective of internal migrants in megalopolises in India.
Lynne Jones will discuss how poor migration management mechanisms can affect the emotional and psychosocial wellbeing of migrants.
I would like to start with Peter. What are the ways in which the COVID-19 crisis is impacting on the lives of refugees, asylum seekers and internally displaced people around the world? How is the current crisis interacting with pre-existing vulnerabilities to create new mental health and psychosocial problems for refugees? What is being done to address this?
Peter Ventevogel (UNHCR):
First of all, it is key to note that in refugee situations, mental health problems are already highly prevalent. WHO estimates that 22% of adults in conflict settings have mental health conditions, almost triple compared to non-conflict settings. This is the baseline, and layering of COVID-19 on top of this makes it even more complicated.
I believe that the majority of the effect of COVID-19 on the mental health of this population will be indirect, and will manifest itself over time. For instance, many people who coped relatively well previously will now be less able to cope because of the multiple stressors generated by the pandemic:
Social support systems may become dysfunctional or overburdened;
Caregivers may become sick or die;
Stress levels increase due to movement restrictions, crowded living conditions and uncertainty about the future;
Income and livelihood opportunities are threatened;
Many, particularly women and children, face increased protection risks including intimate partner violence and sexual abuse and exploitation;
There is rising discrimination and xenophobia in hosting countries and societies
Similarly, people with pre-existing mental health conditions may experience a worsening of their condition and have difficulties in accessing appropriate care: care may not be there, or there may be issues with accessing it.
Unfortunately, the worst is yet to come.
In terms of examples of how it’s possible to respond, let me in the first instance refer to a document from the IASC group, cleared just today: Operational considerations for multisectoral mental health and psychosocial support programmes during the COVID-19 pandemic. This document contains detailed guidance and tips on adapting MHPSS services in humanitarian settings.
In addition, there are a number of key actions that it’s worth flagging explicitly:
Large-scale community messaging about coping with distress: It is important to communicate clearly about risks and ways people can protect themselves, and manage stress in families. Such messages should be delivered in appropriate languages using contextually relevant dissemination methods.
Training first responders in Psychological First Aid and basic psychosocial skills: Psychological First Aid (PFA) is a set of skills to provide supportive and practical help to people suffering crisis events. There is a new tool, developed specifically for COVID-19, to support this, called the “Basic Psychosocial Skills for COVID-19 responders”. While many responders have been trained in PFA, this needs to be taken further, and should be extended to anyone who may need to respond to COVID-19: from nurses and doctors, to police officers, to shop-keepers.
Providing psychological support through helplines: Many helplines have set up or expanded to provide support to people in distress. However, it’s key that these are in the right language, and in the right tone.
Increasing capacity to provide psychological therapies for refugees with mental health issues such as depression, anxiety, and bereavement: This needs to be adapted for the reality of the pandemic, and transferred online. We see this increasingly taking place.
Ensuring continuous care for persons with moderate to severe mental health conditions: Persons with severe mental health conditions should have continued access to clinical and other services. This can be a problem, as some services are blocked, or reconfigured to treat COVID-19. However, essential psychiatric care is essential for survival, so it must happen.
Ensuring that person with severe protection risks continue to receive psychosocial support: Refugees in difficult situations need to be offered psychosocial support. Examples are people in detention, SGBV survivors, unaccompanied or separated children and survivors of torture. They often have challenges to access MHPSS services due to the combination of COVID-19 risks and protection risks. Therefore, additional measures to provide such services are warranted.
Attention for mental health and wellbeing of refugees supporting others in their community: It is essential to pay attention to the mental health and wellbeing of all responders, including refugees who work as volunteers.
Guglielmo Schininà:
Thanks Peter. The tools will be made accessible after the webinar.
I now leave the floor to Teresa who will bring the experiences of Ethiopia. Almost 19,000 Ethiopian migrants came back to their country since the beginning of the pandemic, mainly expelled by Gulf Countries. Theresa, can you tell us about the experience of trying to support migrants returning to Ethiopia, especially those who have to be quarantined upon return. What are their specific mental health and psychosocial needs? What is being done to support them emotionally during the quarantine, and in relation to their unexpected reintegration needs, at times of financial hardship for all?
Theresa Ombalo (WHO):
The issue of migrants in Ethiopia is a peculiar one. Following the introduction of the government quarantine order around the 23rd March, everyone re-entering Ethiopia needed to quarantine for 14 days. While regular travellers could quarantine in hotels, returning migrants had to quarantine in special government centres, e.g. universities.
It’s important to understand the perspective of these people. When they were leaving the country, they had dreams of improving their lives. In Ethiopia, some had been physically abused, or witnessed atrocities. Upon reaching their destination, they thought their lives would change. Instead, they were sent back to Ethiopia. In addition, leaving Ethiopia is not cheap, and many had to borrow money to pay people for passage, leaving behind a debt that they promised to repay after securing jobs abroad.
Thus, there are a number of psychological challenges upon return. Not only do they need to deal with losing their dreams: being forced to come back to a life that they were trying to get away from, and potentially being afraid to face family and friends (especially if they borrowed money). Some of these people have also been traumatised: e.g. seeing friends die, women experiencing sexual abuse and rape (sometimes resulting in a preganancy).
In addition, however, they also need to deal with issues that the pandemic creates (which they may not even have thought about). First, there is often a challenge of communication and the passing of correct information to the migrants: many didn’t know that they would need to quarantine (so were not mentally prepared for this); and did not understand why they needed to live in separate rooms, socially distance, and wear masks. There was a lot of frustration, and took a lot of effort in terms of awareness creation.
To help in the short-term, we sent teams of psychiatrists, psychologists and social workers to set up individual and group counselling to help them understand the situations they find themselves in, and supported referrals to a mental health facility (e.g. for prescriptions) for clients who have needed this to cope.
In addition, we have tried to support our clients in the longer-term as well. Once the returning migrants finish quarantine, they will go back to their home regions, which can be a stressful experience: there are reasons why they left these areas to begin with. Therefore, we have been trying to link them up with local services, so they don’t immediately start the precarious journey out again (as many have been saying is their intention). This has been a challenge, as there are fewer partners for this in the regions vs Addis Ababa.
Guglielmo Schininà:
IOM often deals with returning migrants, and we often don’t have time to prepare migrants for re-integration (e.g. initial shame). While quarantine time could be used for this, unfortunately the situation appears too complex to do this fully.
Rama has been for many years involved in education, rights and citizen programs specifically targeted to marginalized urban communities, including basic support for the urban poor during COVID-19, especially in Mumbai. In India, the lockdown to respond to the COVID-19 crisis resulted in huge numbers of Indian citizens who had migrated internally for work to be stranded and unable to return to their villages and hometowns. In addition, I understood from you that they have faced unequal challenges in accessing the established support mechanisms in the cities in which they are living, like Mumbai. Could you tell us about some of the particular factors that impacted on the mental health and wellbeing of internal migrants in India? What practical support have you seen be effective in addressing this?
Rama Shyam (SNEHA):
By Indian estimates, there are 454M migrants within the country. Between the capital and Mumbai, 43% of both cities are comprised of migrants. Within this context, the difference between migration by choice and migration by force has been thrown into very sharp relief. COVID has distressed the Federal structure of the Indian state: while we say that within India’s borders, we are all Indians, what we are seeing is one of the biggest exoduses of populations since the partition of India.
Speaking to migrants who are still in the big cities, one of their biggest psychological fears is: “What will happen if I die in a quarantine facility, with my loved ones not around me”. People repeatedly talk about their land, their people, their loved ones, and this isolation is compounded by a huge loss of livelihood for internal migrant labourers, who are almost invisible in the urban landscape. These people, who work as drivers, janitors, security guards, tend to come from the remotest and the poorest districts of India. Suddenly, we are witnessing a major ethnic divide within the cities, where one part of the city wants the other part to leave the city, so it is less crowded (notably, Mumbai has one of the highest population densities in the world).
Young people, especially girls, have slightly different challenges. Many of them have spoken about their concern of losing access to education, or losing the ability to choose their partners, if they go back to the more culturally and ethnically traditional setting of the villages. In this way, too, ethnic boundaries are becoming increasingly sharp, with reverse migration from cities back to the villages.
In terms of what we have done to support:
Mapped telephone numbers of people, and are constantly connecting with them to talk, listen, and communicate current information (the lack of this is one of the biggest challenges throughout this pandemic)
Invested in addressing stigma and reducing the issues of the all-pervasive anxiety and fear through video calls, working with the police, neighbours in the community, training volunteers and frontline public health workers
Facilitated access for migrants to public systems responsible for food security, health infrastructure, and addressing domestic violence. Trained migrants to access helplines that have been set up
Assisted migrant workers with documentation to access social protection benefits
Guglielmo Schininà:
Portability of rights is extremely important: especially in bigger countries, health rights are by and large not portable. Migrants often can’t really benefit from the same rights that they have in their hometowns or villages, unless they are able to break through a bureaucratic barrier. This is a key issue.
Lynne, in the last few years, you have been volunteering with groups supporting refugees and asylum seekers in Lesbos and Calais, and have remained connected to them during the COVID-19 crisis. You have been raising concerns about policies and actions of governments that you have described as human rights violations which cause distress and harm to already vulnerable children and adults. You have worked at the center of a contradiction, an hypocrisy that COVID-19 has helped to unveil. Spaces that are created for the alleged security of host communities, like identification centers and administrative detention centers, or spaces created for the protection of migrants, like camps that start as a temporary measure but then are maintained for years, are now, without any possible masking, appearing for what they are: spaces where even basic public health measures are impossible. Not spaces of protection, but spaces of vulnerability for the migrants who live there, and for the communities which surround them.
Can you tell us what the key concerns are, and why they must be addressed to protect the mental health and psychosocial wellbeing of the adults and children in these settings (especially during this pandemic)?
Lynne Jones, OBE (Independent MH Expert & Activist):
I’m going to start with a quote from a young Syrian refugee, who didn’t want to join the fighting on either side, and spent 3 years floating around the asylum system in Greece. What he said sums up the mental health effects of being trapped in this inhumane system: “They put you in a place for making monsters. If you want to turn a peaceful man into a monster just make him wait for things that he does not understand that he is waiting for. Make him swim in the flashbacks of his old life. Just let him lie and stare at the ceiling of the tent, remembering and thinking about every single bad moment through which he passed. You feel like there is a volcano inside you. I am in my twenties. This age is full of energy, and you are lying there doing nothing, so you get panic attacks and feel utterly changed. This is the way to make monsters.”
COVID has brought out how hostile this ‘hostile environment’ really is. It starts outside the country, with constant illegal pushbacks, on land and on sea, towing migrants into other waters; or forcing migrants back into illegal and inhumane detention centres that they left.
If fortunate enough to make it to land, I have never seen the conditions in refugee camps on the Somali border, or in Pakistan, or in other countries, that I have seen in Calais. Conditions are disgusting and inhumane - and they have got far worse under COVID-19. The Moria “prison” contains 6x the number of people vs its intended capacity, camped out on squalid bits of plastic. Pre-COVID-19, they had core access to food and water, provided by volunteers. With COVID-19, this support has diminished; access to healthcare has diminished; access to leaving the camp has been removed.
Greece has handled the pandemic well, lifting lockdown and allowing tourists back. So there is this paradox, of tourists on the beaches; while on World Refugee Day lockdown in the camps as reception areas was extended, with restrictions on movement until July 5th. The conditions are dire: no access to soap and water; one toilet for 200 people; no ability to isolate or quarantine. And in all this space - there is nothing to do, as access to social and education spaces has been withdrawn, as volunteers are no longer allowed in. Asylum applications in Greece have also been withdrawn for 2 months; and even though they have now been re-introduced, this is not something refugees can easily navigate.
The situation of unaccompanied minors is even worse. E.g., 300 are held in “protective care”, in poor conditions and poor access to healthcare; and a further 1,000 are on the streets of Athens.
It’s inexplicable that we don’t do anything about this, as in harming these people we are also harming ourselves.
Guglielmo Schininà asked each panellist for one final recommendation: what can be done?
Peter Ventevogel (UNHCR): It is key to integrate MHPSS in all aspects of humanitarian work, beyond specialists, relevant to everyone. For people who need more intensive mental health care in settings where this is not available (e.g. in remote locations or camps), we need to work with capacity building of general social and health workers at the primary care level, with supervision over the phone (task-sharing). Mental health care is essential health care, and should be part of universal health coverage.
Theresa Ombalo: In Ethiopia, there has actually been an allocation of funding for mental health. In addition, there is a strong network of Healthcare Extension Workers, who are being trained to support people who need mental health care in community (rather than in quarantine centres).
Rama Shyam: As a means of state policy, we need more investment at primary care level of MHPSS. We should build capacities of frontline and community workers. We must treat mental health support as an issue of social justice, not just clinical intervention.
Lynne Jones: It’s not possible to have good mental health if your basic needs aren’t catered for, or if you are not secure. We need to address basic needs of migrants, and stop their discriminatory treatment. The most important solution is political. The reason why Greece, Italy and France are in this situation is because the rest of Europe are refusing to take their share of migrants. We need to lobby politicians to accept refugees into European countries. While we quarrel, we keep refugees in inhumane and degrading conditions. I am ashamed to be European, given that this is the state of affairs in Europe.
Guglielmo Schininà: There is no mental health without rights, and no mental health without humanity. This is true for everyone, and especially for migrants at a time when the migration discourse is so politicised. Unfortunately, the worst may still be to come, due to increased xenophobia and the fear of the “other” that the pandemic may unleash.
Anada Galappatti: Thank you to the panelists. We have been getting great responses from viewers, who thank the panelists for raising these key issues. Please continue to ask questions on twitter using #covid19mh. If you work with refugees or migrants, or are a refugee / migrant, please share your insights and experiences.
