By Shaifali Sandhya, PhD, Clinical Psychologist, Care Family Consultation
This blog is part of a series on tackling COVID-19 in developing countries. Visit the OECD dedicated page to access the OECD’s data, analysis and recommendations on the health, economic, financial and societal impacts of COVID-19 worldwide.
The modern world is in an unprecedented situation. In the last decade, the global population of the forcibly displaced has swelled to 70.8 million; with the advent of COVID-19, its numbers are expected to soar as a staggering number of refugee and asylum-seeker families find themselves further displaced by fear of disease, food insecurity and by the pressures of collapsing national economies. In many countries displaced communities’ access to labour markets is limited to the informal market, and equally vulnerable will be nations’ shadow workers – garbage workers, prostitutes, domestic help, garment makers, and gig workers. Faced with an economic crisis of cataclysmic proportions, economists and political leaders will be tempted to focus solely on the physical and economic facets of the current crisis. But if we want to make it through this crisis, that won’t be enough. In addition to financial and physical wellbeing we will need to recognize and address mental health around the world and at every level of society, especially of its displaced communities. We are at best, unprepared for the worst; for both OECD and developing countries, we need to provide tailored mental health treatment to those who need it in the communities they live in.
Exposed by the coronavirus crisis we will all be affected mentally through losses such as the death of loved ones, illness, diminished life’s savings, or in being confined, having to forgo life’s significant occasions, transitions, plans, or experiences. Since, mental health is intrinsically tied to economic health, untreated, it extracts long-term burdens on society through increased welfare support, disability benefits, absenteeism, violence, functional impairments, and premature death costing over 4% of gross domestic product in EU countries. The pandemic generates fear and anxiety; in restoring economic activity if we don’t address its extensive mental health impact we will not get very far.
For the nations’ displaced communities – for example refugees or asylum seekers – the mental health fallout will be significantly more acute. A recent thirty-year study shows that refugees when they are allowed to work, are important contributors to the economic health of nations. Shadow economies comprising of displaced workers can amount to a large share in the gross domestic product (GDP): 34% in Sub-Sahara Africa and 16.7% in the OECD countries, respectively. This community is a growing part of the front-line economies around the world and the consequences of not addressing their complete needs are severe – personally and collectively.
The displaced are often intimately familiar with psychological trauma. Psychological trauma is the emotional response to experiencing or witnessing a horrifying event. Today’s displaced face reduced access to life-saving healthcare; in prior-traumatized populations additional stress causes physical symptoms with no medically explained basis, to erupt. Refugees for example, exhibit more unexplained somatic symptoms compared to most other populations:
“They say ‘you should integrate’ but how? … when my children and I cannot even sleep.”
–Mrs. Khan, Syrian, female, refugee
“Only I feel the pain so it is a relief to know that no one else can know my shame.”
–Ahmad, Iraqi, male, torture survivor
The greater the trauma of a vulnerable population, the more powerless it feels, and the more it relies on the silent language of the body: vague but pernicious stomach-ache, chronic fatigue, migraines, jaw-clenching, irritable bowel syndrome, or trembling. Being marginalized can coincide with lower levels of education and socio-economic status that also correlate highly with physical expressions of distress. If language is elusive in deciphering their pain, how do we prioritize mental health? In Carroll’s Alice in Wonderland, Alice climbs through a mirror to see into her world. She discovers that in order to comprehend its inner workings that she has do things differently.
Prioritizing mental health means broadening our looking glass to see how our social world affects our emotional health and the multifarious forms of mental distress in populations different from us. Different cultural meanings can drive physical symptoms: a perception of intense heat or “calorias” affects Salvadoran refugees; hallucinations of vengeful spirits can consume Cambodians; headaches affect Syrians; and a tingling called jhum-jhum afflicts the Nepali. Symptoms are not equivalent and nor they just a disease-index; they are a window to understanding the rich tapestry of social and cultural factors undergirding people’s emotional life holding a crucible of meanings: social discontent; an intrapsychic conflict; deep distress; or how patients may negotiate their local worlds. There is much value to be gained in opening a window to the meanings of a symptom.
Addressing the mental health of the displaced will require tailoring approaches to the needs of individual communities and host environments, a differentiated and not a one-size-fits-all approach. Symptoms reveal: impediments to a community’s progress that may have otherwise lay hidden; cultural beliefs about emotional health; or even beliefs that can influence the illness itself. In contrast, not swinging open the world lurking behind the symptom can circumscribe how we treat health, in restrictive and myopic ways, and who we treat. In excluding this language of emotional pain of the world’s marginalized are also lost opportunities of elevating their potential and empowering communities. Language has been identified as a huge barrier to keeping displaced populations well informed and avoiding misinformation about the spread of the COVID-19 virus. Additionally, if language is incomplete in capturing distress among the marginalized, we may also need to rethink how we collect data and what kinds of data to collect within these populations.
To restore economic activity in the aftermath of the pandemic, besides financial and physical well-being we must push to address mental health of individuals and communities. If we want peaceful societies, high in economic growth and stability, and low in social cleavages, we must especially include the displaced communities and tailor mental-health approaches based on their unique contexts. A starting point proposed by the WHO for refugees in the European region is to build on existing health system policies and infrastructure to ensure that refugees have routine access to regular health services, implying that existing health systems will need to be more sensitive to their needs. Others advocate for training medical staff in refugee camps so they can apply psychological first aid and working closely with community leaders.
Developments like the International Conference on Mental Health and Psychosocial Support in Crisis Situations hosted by the Netherlands and the focus on improving self-reliance, including through mental health of the Global Compact on Refugees show increasing recognition of the importance of addressing the need for mental health and psychosocial support in emergencies. Around the world, however, most mental health concerns remain untreated and mental health systems are in crisis. Furthermore, “the added threat of COVID-19 comes at a time when mental health and psychosocial support services are either interrupted or suffering from limited resources in country after country”, according to the UN’s Global Humanitarian Response Plan (GHRP).
A transformation in the way we treat mental health can only begin with whether and how we think of the mental health of society’s marginalized, and those will only be our first steps. How we support and care for the displaced shapes the society we want to be in the future. Addressing all facets of this crisis – physical, social, and mental – is not just humane but also economical and if we fail to do it, we will be standing on the precipice of our next crisis.