The current crisis in Syria has very explicitly brought the plight of refugees to global attention. Since 2011 over half of the population have been displaced, while around 8 million people have been internally displaced, a further 4 million registered refugees have left Syria and fled to neighbouring countries and beyond (UNHCR, 2015). One of the many challenges generated by this crisis is how host countries of refugee populations can respond to the health needs, and particularly mental health, of those who have fled the trauma and violence of events in Syria. Data from the WHO has shown that the psychological and social stresses often experienced by refugees during migration can double the prevalence of severe disorders (psychosis, severe depression and disabling anxiety), and increase the figures of mild to moderate mental disorders from 10% to 15-20% (WHO, 2012). This points to the need for appropriate models of care. Mental health interventions are often developed around ‘Western’ understandings of mental health and well-being that may not appear to have relevance in other cultural contexts. In other settings such as much of the Arabic world and in parts of Latin America cultural idioms of distress – or the ways in which people express distress within a particular culture or community – do not necessarily see physical and mental health as being distinct but one is often understood as a manifestation of the other. This can mean that individuals may initially present themselves to health practitioners with a physical ailment before addressing the psychological or spiritual dimensions of their condition and so there is a need for health professionals to work to draw out the perceived underlying causes of the problem.
Learning from past generations of refugees
In this context it is important to consider what lessons can be learned from previous generations of refugees who have escaped wars, military dictatorships and other large scale traumatic situations. Within the UK, the case of Chilean refugees offers some potentially valuable lessons for identifying and addressing the mental health needs of the victims of forced migration. Following the brutal military coup led by Augusto Pinochet on 11th September 1973 around 200,000 Chileans were exiled internationally, 3,000 of whom came to the UK. While democracy was finally restored in 1990 and many of those exiled returned to Chile, others decided to stay in the UK.
The experience of Chilean refugees to Britain in the 1970s
Research by Jasmine Gideon at Birkbeck, University of London has focused on how these Chilean refugees coped with life in exile and what this has meant for their health and well-being. Many of those exiled to Britain were political prisoners who came directly from prison where they had been tortured and friends and family members ‘disappeared’ by the regime. Although many of the exiles received medical attention for the physical symptoms of their incarceration, very few received any interventions to address their mental health needs. Yet in the absence of formal support many of the ex-political prisoners found alternative ways of dealing with the trauma they had experienced – often through diverse forms of political and community activism in the UK and maintaining political links in Chile. Nevertheless even four decades later many are still dealing with the long term health implications of their experiences and have sought redress from the Chilean government.
Who counts as a refugee?
The experience of Chilean exiles also highlights the importance of considering the mental health needs of family members of victims of torture. In the Chilean case a large number – but not all – of the political prisoners were men who came to the UK accompanied by their wives and children. However very little consideration was ever given to these women’s needs as they were frequently viewed as ‘accompanying spouses’ rather than ‘legitimate’ refugees and because they had not experienced torture or imprisonment they were not considered to have any mental health needs. Nevertheless, my research found that many of these women did experience depression, anxiety and other mental health disorders following their arrival in the UK. These women faced considerable challenges caring for men who were ‘damaged’ by their experiences as well as enduring different types of trauma including having to protect their children from the realities of what was happening to the family. Moreover, before leaving Chile many of the women had been forced to search for family members who were disappeared or try to locate their husbands once they were arrested and were often subject to sexual abuse in the process. In addition in some instances men were tortured in front of their wives and often in the family home. Even after reaching the relative safety of the UK these women were responsible for having to re-create a ‘home’ in the UK following exile, often despite the fact that they spoke little or no English and had to do so while being completely cut off from their kinship networks. This produced high levels of anxiety for many women and several experienced breakdowns in the early years of exile.
Defining refugees for appropriate health interventions
Where mental health interventions are available they are often underpinned by implicit assumptions that forced migrants are men who have experienced torture and their health needs arise from this particular experience. However, my study points to the need for a broader understanding of who constitutes a ‘legitimate’ refugee and how this has frequently been shaped by gendered assumptions about men and women’s roles and how far their activities and responsibilities might expose them to health risks, including mental health. While women may not always take on such public roles as men in wars and during periods of military repression that may result in them subsequently becoming refugees, this does not prevent their exposure to the same mental health risks as male refugees. The Chilean experience highlights the need for a broader understanding of what constitutes a victim of forced migration and this must feed into the design and implementation of health-related support programmes to ensure that the longer term health and well-being needs of refugees and exiles are fully addressed. The issues raised here are discussed in more detail in The Handbook of Migration and Health.