The Toll Of Refugee Life On Rohingya Mental Health

Life has changed drastically over the past few months for the young Rohingya refugee. In May 2023, Haris had to quit school in Delhi after his mother reluctantly asked him to return to Bengaluru. A chronic backache--caused by the laborious chore of picking waste each day for a decade to support her family--had become unsustainable. Her husband, who is mostly confined to their home due to a gunshot injury to his leg while escaping violence in their homeland of Rakhine in western Myanmar bordering Bangladesh, is unable to contribute. His estranged elder brother has moved to Delhi with his family, forcing Haris to now take up the mantle of responsibility for his two younger siblings, who are under 10 years old.

This has had a cascading effect on his prospects of completing his formal schooling, and has affected his mental well-being. When Haris’s school friends in Delhi call, out of shame, he does not tell them that he is now a waste picker.

“I feel ashamed and sad, and ask God why I have to do this work. My parents want to see me as a professional,” said Haris in fluent English. His mother Farha, who teared up at her son’s plight, wants him to study and get a job, but “we cannot starve”. He usually goes out after sunset so that others do not see an educated boy doing such work, she said.

Although Chemistry is his favourite subject, he has opted for Commerce in his open schooling programme as it requires less focused effort and is not as expensive. “I do not know how long I can keep doing this [work],” said Haris. “If this goes on, it will not be good for me. I don’t discuss it with my parents because they will feel sad.”

A report by the International Organization for Migration (IOM) in June 2021 from Cox’s Bazaar refugee settlement in Bangladesh on the mental health and psychosocial support (MHPSS) of Rohingya refugees and the host communities showed that more than 60% felt the main stressor was basic living needs and conditions. Education (43.2%), safety and protection (23.7%), uncertainty (23%), livelihoods (18.9%), poor health conditions (18%), displacement and sense of loss also ranked high in the list of concerns.

India hosts more than 212,000 refugees and asylum seekers. Of these, 22,110 are Rohingya refugees and asylum seekers, which is 2% of the nearly 1.1 million Rohingya refugees and asylum seekers reported by the United Nations High Commissioner for Refugees (UNHCR) outside Myanmar.

In the second part of our series on healthcare access, IndiaSpend reported from Bengaluru, Delhi and Nuh on the mental health support and challenges that Rohingya refugees and asylum seekers in India face. You can read the first part, on healthcare access for Rohingya refugees, here.

Predominantly Muslim and stateless, Rohingya people are “the most persecuted minority in the world”. We met refugees whose family members are dealing with mental illness, and others whose family members have been detained and who are struggling to establish a secure livelihood.

Most of the refugees have faced violence and trauma before they fled Myanmar, and many continue to live in fear of detention and deportation. Their problems are compounded by lack of documentation, which limits their opportunities to thrive in a host country. This has affected refugees’ mental well-being and necessitates MHPSS, experts told IndiaSpend.

‘Probably due to refugee life’

Farook* and Shireen* live 80 km away in their respective Rohingya settlements in Delhi and Nuh. Apart from their worries around food, health and wages, they have one thing in common: They were caring for a family member struggling with mental health issues.

Farook’s wife, 24-year-old Reena*, who was pregnant, has been diagnosed with severe depressive disorder with dissociative symptoms at a government hospital in Delhi they visit at least a couple of times a month. She loses consciousness for sustained periods, particularly when she hears loud sounds. She is unable to associate with the people around her, including Farook and their first-born child.

“She has tried to hurt herself a few times. I cannot step out without worrying due to her condition,” said Farook, when IndiaSpend met him in September. “Even during Diwali, she fainted due to the loud sounds which remind her of the violence and trauma back in Myanmar.”

According to the World Health Organization’s (WHO) review of 129 studies in 39 countries published in June 2019, among people who have experienced war or other conflict in the previous 10 years, one in five people (22%) will have depression, anxiety, post-traumatic stress disorder (PTSD), bipolar disorder or schizophrenia.

Farook, who delivers furniture on a rickshaw, has borrowed money from relatives and moved out of the tented Rohingya settlement to a room nearby. The rent is Rs 3,000 a month, more than a third of his wages. For nearly a year now, he too has been on medication for depression.

“I feel angry and frustrated,” he said. “The doctor said that it is probably due to refugee life.”

The family is able to access the services of a specialist a few times a month, and if they do not get free medicines, they are able to buy what they need through support from the UNHCR-implementing NGO.

“UNHCR and its NGO partners conduct regular meetings with refugees, asylum-seekers and partners and extend psychosocial counselling support to them,” UNHCR India told IndiaSpend. All refugees registered with UNHCR receive assistance which includes advocacy for access to basic healthcare and psycho-social counselling support, they said.

Vulnerable families like Farook and Reena’s get Rs 4,000 a month as financial support, which in their case covers their medical requirements, rent, and buying infant formula for their one-month-old child. “She has been asked not to breastfeed after one hour of consuming her medicines,” said Farook. “It is difficult for us.”

Shireen is in similar circumstances. When IndiaSpend met her in Nuh in September, she was trying to calm her mother-in-law, who was crying (and who has since died, in October). She had been mentally disturbed ever since her son, Shireen's husband, was detained by the police after the Nuh riots in August. Shireen did not have any information on her husband for nearly a week after his detention. He was eventually released on bail in early September.

“My mother-in-law has age-related health issues but she had never behaved like this. She walks out, sometimes without being dressed,” said Shireen. “She keeps crying. I am tired of handling her and have to tie her to the cot because I do not know where she will go when I am not around.”

The detention has impacted Shireen too, who was unable to explain to her young children about their father’s whereabouts. “I feel sad and depressed and have not slept properly since his detention.”

Her husband Nasir* said that he found Shireen complaining of headache and tiredness ever since his return from detention, which he thinks is probably because of the stress. His fear now is about being arrested again and deported to Myanmar, where there is a definite threat to life for Rohingya people. “Before being picked up for no fault of mine, my worry was to save money for my child’s operation [he suffers from gastrointestinal issues], which will cost around Rs 35,000 [in a private hospital].” he said. “Now I have to pay Rs 45,000 to the lawyer, and worry about being arrested again. I do not want to be deported. I would rather be in jail here.”

A similar worry lurks in the mind of Asif*, who lives a few kilometres away from Shireen and Nasir. His 14-year-old son Javed* was released from the child care centre after being detained for 40 days following the Nuh riots in August. Although Asif was relieved that his teenage son was with him, the fear of Javed being arrested again lingers. He was picked up on false charges, Asif claimed. “My wife and I are always worried and fearful these days and remain tense,” said Asif. “We are refugees, what can we do?”

Trauma and mental health

As we reported in the first part of this series, the Union government deems Rohingya to be “illegal migrants” who “pose a threat to national security”. This complicates matters because India is not a signatory to the 1951 UN Convention relating to the Status of Refugees and the 1967 Protocol, which defines rights and protections for refugees based on which the UNHCR works.

Estimates of mental disorders, while being essential information, fail to do justice to the more complex multi-faceted psychosocial challenges of the Rohingyas that cannot be merely viewed through a ‘medicalised’ lens, said a December 2021 paper by Nivedita Sudheer and Debanjan Banerjee. Many of their mental health challenges appear as ‘survival threats’ which need integration into public health to improve their quality of life, said the paper.

According to a December 2020 participatory action research study in the Cox’s Bazar refugee camp in Bangladesh by a team of Rohingya researchers trained by Fortify Rights, a human rights network, ongoing human rights violations and abuses committed with “impunity in Myanmar and Bangladesh have resulted in severe and long-term mental harm among the Rohingya refugee population”.

Around 89% of Rohingya participants in the survey reported experiencing symptoms indicative of depression; 84% reported symptoms indicative of emotional distress; and 61% reported symptoms indicative of PTSD.

The unique circumstances of stateless communities increase the risk of human rights violations and can lead to precarious living conditions while these communities struggle to be recognised and build their identity, said Stella Dermosoniadi, a clinical psychologist/MHPSS professional who has worked with refugees including Rohingya in Bangladesh. “...Refugee stateless individuals and communities often feel that they “don’t belong”, as they are not recognised and are invisible by states, legal entities, and the media.”

Reena, who has witnessed violence and death in Myanmar before she escaped with her family to Cox’s Bazaar and then travelled to India, said that gunfire and bombs have created the fear that someone was always coming to hurt them. “Even the smallest sound like an ambulance or people shouting gives me anxiety,” she said.

She always aspired to higher studies, and helped Rohingya girls learn the Burmese language. She tried to continue her education in India, but though she did well in her grade IX exams, she became unwell and fell unconscious in the exam hall during her grade X examinations.

“My aspirations have not been met for so long,” said Reena. “We keep getting called infiltrators and this impacts me. I feel that the same incidents in Myanmar will repeat here. We are humans, not animals.”

Dissociation is a way of coping that can be observed in people who have experienced trauma, such as sexual abuse survivors, said Bipasha Biswas, faculty at the School of Social Work, Eastern Washington University, who has worked with refugee communities including Rohingya in the US. “It is a physiological manifestation where your brain shuts down certain memories of the traumatic event. Dissociation is not necessarily always maladaptive, but it should not become a stigmatising mental health diagnosis following which a person is pumped with a lot of medication.”

Efforts for mental health support need to expand

India’s structure for mental health support and expenditure has been underwhelming. The total budget outlay for health and related programmes for 2023-24 was 2% of the fiscal outlay of the Union government, said the budget analysis by Centre for Mental Health Law & Policy Indian Law Society-India Mental Health Observatory (CMHLP). At Rs 919 crore, the budget for mental health is just above 1% of the total budget of the Ministry of Health and Family Welfare, it said.

On average, Rs 2,115 is spent each month on healthcare by a household, if a member has a mental illness. This adds up to 18.1% of the household’s monthly expenditure, IndiaSpend reported based on the financial impact of mental healthcare and the need for financial risk protection for households with members suffering from mental illness.

In October, in response to a Right to Information request filed by IndiaSpend on support for mental health care for refugees, the mental health division of the MoHFW said that the information may be treated as “nil”, and transferred the request to the Ministry of Home Affairs.

The All India Institute of Speech and Hearing, Mysore, one of the departments/institutes under the ministry to which the request was forwarded, said that its department of clinical psychology provided treatment to “all the patients who are in need of such services”. It did not specify if refugees were specifically included.

Currently, psychosocial counselling is provided through NGOs associated with UNHCR in India, who function with limitations. The informality of Rohingya’s housing and work, and the constant surveillance by authorities, puts pressure on the community. Although they may not formally communicate or articulate the need for mental health care and support, there is a requirement for such support, experts say.

There is no enabling environment to discuss these issues as it is a fight for survival even when there are symptoms of depression like hopelessness or helplessness, said Aqsa Shaikh, a medical doctor and community medicine specialist who has treated Rohingya refugees in Delhi NCR. “It might be construed as issues faced by refugees generally, and not really investigated…. [and] when they visit primary healthcare providers, there is poor knowledge and empathy towards them.”

In Delhi, the Azadi Project, a non-profit, is providing leadership, livelihood skills, and psychosocial support to women from refugee and marginalised communities. They are working with Rohingya women and younger and adolescent boys on mental health.

Mental health becomes a priority for refugees when it becomes severe, said Priyali Sur, founder and executive director of the Azadi Project. On a daily basis, the concerns are about something as basic as access to a toilet. But getting everyone on board--particularly men within the Rohingya community--to discuss mental health is difficult.

“Every time we try to gather men, they do not come,” said Sur. “So we are encouraging younger adolescent boys to join and speak about male toxicity and gender-based violence. They are very interested. It is difficult to change attitudes even among women, but these conversations are happening.”

As their group consists of women, they have openly spoken about anxiety and depression and the recurrence of trauma. “At least within the group I have not seen them stigmatise each other. If they did stigmatise outside, I do not think they would open up during these conversations,” said Sur.

There have been efforts to involve the Rohingya community to identify and support MHPSS. Nilofer* is a Rohingya refugee in Hyderabad who works as a barefoot counsellor for an NGO that works with the refugees. She has been in India for nearly a decade and, as the eldest child, she has been supporting her siblings over the years through her work as a teacher, translator and now counsellor.

Since 2022, she is part of a team including 10 barefoot counsellors and 10 health volunteers and mobilisers--who are locals from the host community--among others. She and other barefoot counsellors have been trained by the NGO in first aid counselling, handling confrontational situations and gender-based violence, counselling couples etc. She visits door to door, and builds a rapport within the community.

“We visit at least 20 households daily,” said Nilofer. “Initially, it was difficult to talk about mental health issues. Now we have a better rapport. Many people have relationship issues and women's health issues.”

In her time as a barefoot counsellor, she has handled around 70 cases and the majority of these have been related to gender-based violence.

Attitudes are changing slowly, and more women are being allowed to work. Home deliveries have also reduced, but even now 20% of children are delivered at home. “This is happening due to our intervention. We inform them about hygiene and menstruation. This is also part of mental health support to change attitudes that help women in speaking openly.”

Host community needs to be welcoming

In Bengaluru, Haris said that no one has asked about his mental health, but it would be “good” to get that support. But he was also conscious of the lack of awareness of such issues within the community.

Experts said that it is important to support refugees in order for them to communicate their issues, which require empathetic host communities. Mental health support has to be integrated into the primary healthcare system. It is also vital that the refugee community’s capacity is strengthened and mobilised. An example of it is the services Nilofer and her colleagues provide.

Not everyone has the language to connect their experiences with trauma, however. While some may experience symptoms such as anxiety and depression, some may experience it in their bodies, said Biswas.

“It is important that the host community is able to welcome refugees as true neighbours and not exercise a saviour complex,” she said. “Mental illness such as depression is stigmatising in the Indian context.”

The services should offer strong referral pathways and link governmental and NGO services and government policy on mental health policies in place, including a framework for providing services to refugees.

“It is proven that most individuals heal within their communities when they have access to services, community networks, and support,” said Dermosoniadi.

Farook realises that he and Reena are not the only people in the community who may be depressed and require MHPSS. “Some can deal with it and some cannot,” he said.

Series concluded. You can read the first part here.

Illustrations by Gulal Salil

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