Protecting the Mental Health of Refugees and Migrants: Challenges and Possible Solutions
By Rosemary James, IGHN Board Member
A recap from the Panel Discussion at the Berlin World Health Summit (Oct. 27, 2019)
I recently spent some time in Swiss specialized primary care centres for refugees and asylum seekers. I will never forget a young Eritrean man who presented with an open leg wound. To arrive in Switzerland, he travelled to Italy from Libya. His boat had 400 passengers, and 360 of them drowned. He told me how he still awakes every night, hearing the screams of the drowning children. For the past four years he has been living in Switzerland’s equivalent of Ireland’s ‘direct provision’ – allocated basic housing, without the right to work, while he awaits asylum status.
Now that Eritrea has been declared ‘safe’ for return, he will soon be expelled from Switzerland. If he does not leave, according to strict regulations, being locked in prison is a likely fate for this man. According to the most recent figures, 71.4% of prisoners in Switzerland are foreign (Aebi & Tiago, 2018). According to a SwissInfo report, he is one of many in this traumatic situation.
What struck me most about this case is that he has been living in one of the richest countries in the world, with one of the best health systems, and he had not had referral to any mental health services. We screen for active tuberculosis infection upon entry to Europe, but mental health checks seem to be the last concern.
I jumped out of my seat when I saw this session, “Protecting the Mental Health of Refugees and Migrants” was taking place at Berlin’s 11th annual World Health Summit (WHS). After being exposed to the dark realities of the mental health of migrants as a medical student, also in Uganda, Canada and Ireland, I have become keen to learn more about what is being done by governments and civil society to protect these vulnerable populations.
This 1.5-hour seminar was not nearly enough to address the immense challenges we face with meeting the mental health needs of migrants, but it is a start. Here I summarize the interesting solutions which were presented.
Need for a coordinated health systems response
Presented by: Dr. Miriam Orcutt, Executive Director, Lancet Migration, United Kingdom
A brilliant researcher and medical doctor, Dr Miriam Orcutt, Chair of the UCL-Lancet Commission on Migration and Health, spoke about the stark situation in Greece and Lebanon. In Greece, many migrants are under ‘containment’, which means they are unable to move from their situation until asylum is approved.
A 2017 Doctors Without Borders report on the notorious Samos and Lesvos Moria camps slammed the living conditions, yet no improvement has been seen since. A 2018 BBC Documentary confirmed this for me. Moria is currently at four-times its capacity.
With winter around the corner, the many NGOs in the region are preparing for even more overcrowding. Dr Orcutt noted that 20% are minors, those most vulnerable to mental distress. In Lebanon, there are also huge numbers of Syrian refugees. The host populations are struggling to provide merely the essential mental health services for their own communities, yet alone the influx of migrants.
Dr Orcutt gave two important tips to policy makers – First, don’t create parallel systems. It is more effective to improve existing structures, which will strengthen the health system and avoid host-populations being neglected. Secondly, multilateral funding should be provided. This means that the aid is arranged by an international organization such as a UN organization or World Bank and comes from multiple governments and organisations. She ended by quoting the UCL–Lancet Commission on Migration and Health, reminding us that, “worldwide mobility is our future- regardless of laws and walls”.
Counselling for Afghans in Tehran
Presented by: Prof. Dr. Amirhossein Takian, Chair of Global Health & Public Policy, Tehran University of Medical Sciences, Iran
Dr. Takian, a Professor of Global Health & Public Policy at Tehran University, gave a very insightful presentation about what his city is doing to protect the mental health of migrants. He began by explaining that in Iran, there is an estimated two million undocumented migrants, the majority Afghans, with one-third suffering psychiatric problems. He cautioned, the challenge is not only for the refugees themselves, but for the health system and host population too.
In Tehran, the Ministry of Health (MoH) works together with the state welfare organization, NGOs, the private sector, and local municipalities. The state offers free access to primary health care (PHC) mental health services – with public health insurance for refugees after HTP. Unfortunately, according to recent figures, less than 10% of Afghans applied for free universal health coverage (UHC), because they fear deportation, he explained.
In Tehran, there is a UN Centre for the Development of the Mental Health of Migrants. It is equipped with 30 psychologists, whom are all Afghan. It offers many types of counselling and conducts clinical research. He highlighted that this integrates services within the community, rather than a centralised parallel system.
Finally, Dr Takian reminded us that education is key. To address the education of health workers and health students, he designed a mandatory course for the medical students in Tehran to be brought on field visits to learn about the social determinants of health first-hand. He noted, equally important is access to physical and mental health and wellbeing education for the migrant Afghan children, which in turn then empowers their parents.
As many countries, especially in Africa, do not have the health worker capacity -with a mere one or two psychiatrists per country, and where mental health is still stigmatized –he said we must be realistic, and implement solutions that are suitable for such low-resource environments.
Psychosocial support project for Syrian children in Turkey
Presented by: Prof. Dr. Selma Karabey, Professor of Public Health, Istanbul University, Turkey
Next, Professor Karabey spoke about her incredible community-based approach to helping young refugees in primary schools. As there is a lack of health workforce in Turkey, she decided to change the paradigm and use teachers and NGOs to provide local interventions. Funded by the European Commission, her project was carried out over 18-months in Istanbul.
Working with 17 NGOs and 120 teachers in 32 schools, her team provides art therapy, group therapy, board games and Eye Movement Desensitization and Reprocessing (EMDR) techniques as services for improving the mental health of children ages 7-11. The project aims to reduce discrimination and xenophobia. As most of the refugee children do not speak Turkish, they often feel isolated. All material was bilingual.
She first conducted a need analysis, from which a 10-week curriculum was developed. Remarkably, a change in the children’s before-and-after drawings was observed. She showed pictures of dark and uninspired art, and post-intervention the drawings were clearly more colourful and familiar.
You can read more about the innovative project here and here. What interested me from this presentation was the effectiveness and low-resource requirement for mental health improvement in refugee populations. I found that EMDR is also being studied in Turkish refugee camps, and has been shown to reduce Post-Traumatic Stress Disorder (PTSD) and depression symptoms after five sessions (Acarturk, 2016).
Refugee clinics provided by Charité Berlin
Presented by: Prof. Dr. Joachim Seybold, Deputy Medical Director, Charité – Universitätsmedizin Berlin, Germany
Germany experienced huge influx of refugees in 2015-16, the majority originating from Syria, Iraq, Albania, Kosovo, Iran, Nigeria, Turkey, and Afghanistan. Germany has 16 states, all with their own refugee (which they define as a registered asylum seeker) procedures. Struggling to cope with the influx, housing and registration was provided in 2015, but only emergency health services. This meant mental health was completely neglected.
As a reaction in Berlin, Prof. Seybold explained how volunteers and Charité hospital staff began to provide basic health services through clinics and a vaccination bus. They saw on average 200 patients per day. From this, a ‘Central clearing clinic for mental health’, a sort of triage system, was established. Charité equipped it with one paediatric and two adult psychiatrists, one of which speaks Arabic. Translators and an online interpretation system were also installed. Access is for anyone, no documents needed. They currently see approximately twenty patients per day. Unipolar depression is the most common diagnosis in this clinic (40%), second to PTSD (24%), adjustment disorder (19,6%), anxiety disorder (4,6%) and addiction (4,5%).
Prof. Seybold warned that, “people focus too much and only on somatic disorders”. Read more about Charité’s innovative model and clinical studies here.
Presented by: Dr. Santino Severoni, Public Health and Migration Coordinator, WHO Regional Office for Europe
In closing, Dr Severoni, Regional Coordinator for Migration Health for the WHO European Region took the stage. He stressed that non-communicable diseases, such as mental health conditions, “require stronger political decision than communicable diseases.”
He explained that according to regional country data, we have a rough estimate that the prevalence of mood disorders in migrants is between 4% and 40% of migrants, with depression being the most common. So many assume that PTSD is most common, but this is not the reality.
However, he explained that we do not yet have a big picture on mental health status of migrants, as no large studies have been done, and no routine documentation of country level mental health services is available. Further, the mental health workforce is strained.
“No country has yet to address the HRH competencies for migrant health”, in quality nor quantity. So, what is WHO’s view on the best way to improve migrant mental health through health systems strengthening? An integrated PHC approach. Dr Severoni said that Portugal is a good example – where they offer a ‘one-stop shop’ for PHC, inclusive for migrants. He urged other countries to share good practice examples, so that we can learn from each other.
Not surprisingly, the presentations sparked a lively debate in the audience. A common concern raised was that many interventions to address the mental health of migrants are thought to be negatively impacting on the host communities, as NGOs provide extra attention to the migrants, and establish parallel, sometimes better-paying services on the side to the state-run health system. This tension was cut with the speaker’s suggestion that interventions must be integrated into local health systems rather than alongside.
What do I hope for? I hope that projects such as Prof Karabey’s are not simply for 18 months, that they become adopted by ministries of health and are kept sustainable and locally-run. I hope that more high-level discussions like this will be held for years to come – that mental health is not simply a fading trend but considered paramount in all discussions regarding migrant health.
I hope that one day, refugees do not have to be referred to as refugees – that they can be considered equal to the host population, in rights and access to care. I hope that more funding and research is done toward sustainably and cost-effectively improving migrant mental health. I hope that politicians begin to act, and that civil society and the general public continue this important conversation.
In sum, this session provided politicians, students and academics alike, with food for thought. How can we work together to create integrated, primary care-based, specialized services that are accommodating to migrant needs, including language and documentation barriers? An audience member, a consultant refugee psychiatrist from Stockholm, put it well – “we have the evidence, we now need the policy makers to act.” To attain the sustainable development goals by 2030, improving and protecting mental health of those most vulnerable is crucial. There is no time to waste.
Acarturk, C., Konuk, E., Cetinkaya, M., Senay, I., Sijbrandij, M., Gulen, B., & Cuijpers, P. (2016). The efficacy of eye movement desensitization and reprocessing for post-traumatic stress disorder and depression among Syrian refugees: Results of a randomized controlled trial. Psychological medicine, 46(12), 2583-2593.
Bempong, N. E., Sheath, D., Seybold, J., Flahault, A., Depoux, A., & Saso, L. (2019). Critical reflections, challenges and solutions for migrant and refugee health: 2nd M8 Alliance Expert Meeting.
Bhugra, D. (2004). Migration and mental health. Acta psychiatrica scandinavica, 109(4), 243-258.
Mossialos, E., Wenzl, M., Osborn, R., & Sarnak, D. (2016). 2015 international profiles of health care systems. Canadian Agency for Drugs and Technologies in Health.
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