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Rohingya refugee crisis: Unseen wounds need to heal
A loudspeaker from the mosque in Jamtoli comes to life at an unscheduled hour. Instead of the midday call to prayer, an imam asks his listeners to pay attention to their daily anxieties and seek help at the nearby MSF primary health centre.
“The community trusts me, I believe mental health programmes are needed for everyone’s peace of mind,” says Imam Sayeed Abdul Majeed (name changed upon request).
Almost all Imam Majeed’s listeners are Rohingya refugees who fled targeted violence against them in Rakhine state, Myanmar in August 2017. Before escaping to safety in Bangladesh, many refugees directly experienced or witnessed significant violence and many lost immediate family members. In the camps, they live in cramped, overcrowded makeshift shelters, without enough food, clean water or toilets. Their lives are on hold, their futures uncertain.
"Aggressive behaviour, substance addiction, suicidal tendencies are symptoms of trauma and unresolved grief suffered in Myanmar.”
“We are increasingly seeing new cases of generalised anxiety and depression,” says Pooja Iyer, MSF’s psychologist in the Jamtoli and Hakimpara health centres. While physical wounds may have healed, the memories of violence and loss of families through death or separation are still alive.
Two years on, mental health needs have evolved. Traumatic memories combined with unemployment, anxiety about the future, poor living conditions and little or no access to basic services such as formal education leave the Rohingya vulnerable to long-term psychological harm.
Photostory: Abdul Hashim and Abdul Halim, 17-year-old Rohingya twins
“They didn’t behave like 17-year-olds, but like children,” says Ghulbahar of her twin sons, Abdul Hashim and Abdul Halim. “They didn’t sleep and they didn’t listen to me or other relatives.”
The brothers were diagnosed with psychosis – a loss of contact with reality. Psychosis is a severe mental disorder that can require lifelong psychotropic treatment.
“I took them to the traditional healer first but they didn’t get better. Then I met an MSF health educator who asked me to bring them to the health centre in Jamtoli, where they received medication,” says Ghulbahar.
“I want to work and get married. I want to start a family,” says Hashim
“I want to go back to Myanmar. Myanmar is Myanmar – it is my homeland.”
“I feel more comfortable now. Before the treatment, their condition was not good. Today they are better. They rest, sleep – they live like the rest of us.”
The twins mostly stay at home unless there is a food distribution in the camps. Ghulbahar hopes that they will be able to find work and earn a living. “They don’t have enough work experience or education, but they will try. We have been living in the camp for nearly two years,” she says.
“Before their treatment, the twins were running all over the camp and wouldn’t stay at home. I am happy they are better," says Abdul Rehman, Hashim and Halim’s grandfather.
“When the twins first came to our facility in Jamtoli in April 2018, it was difficult for them to sit still,” remembers Ridoan, MSF counsellor. “They could not even sit in our room for a full counselling session of 10 or 15 minutes. They would just run around the facility. Our community mental health educator would visit them to make sure they took their medication on time.”
Initially the twins’ family thought the treatment wasn’t working, as the medication and counselling sessions need a consistent follow up to be effective.
“We have a plan for each of our patients, devised by a team of counsellors, psychologist supervisors and the psychiatrist,” says Ridoan. “Today the twins have improved. They eat regularly, are thinking of getting a job, and are more sociable.”
Gaps in mental healthcare
Nearly 450 patients seek mental health counselling in the Jamtoli and Hakimpara health facilities alone. The prevalence of chronic psychosis – a severe mental disorder that requires psychotropic treatment – is high among MSF patients. When 17-year-old Rohingya twins Abdul Hasim and Abdul Halim first came to the Jamtoli health centre, they behaved like children and were disconnected from reality. Disorganised thinking, seeing or hearing things that are not present and behaviours like the ones exhibited by the twins, are typical signs of psychosis.
Many MSF patients complain of nightmares and flashbacks. Aggressiveness, suicidal tendencies, delusions, and substance addiction are also common. MSF psychologists say they are symptoms of trauma and unresolved grief. Many patients have bipolar disorder, schizophrenia or other psychoses, and psychological difficulties linked to epilepsy.
At the beginning of the 2017 influx, psychosocial support was key to helping survivors cope with the trauma of suffering extreme violence. Today, psychiatric care, combined with psychosocial support, is essential to alleviating the mental health conditions prevalent in the camp. It remains an unaddressed gap. Increasing long-term comprehensive mental health services implies additional resources and personnel to evaluate the true extent of mental health issues. The health response needs trained psychiatrists who can diagnose and prescribe medicines to treat severe mental disorders.
Another gap is services for children with developmental, neurological or learning disabilities or delays.
“We have patients with cerebral palsy, attention hyperactivity deficit and autism-spectrum disorders who cannot go to a regular school or a learning centre, as they get teased and bullied,” says Iyer. “They suffer in silence.”
MSF health facilities across the Cox’s Bazar district, which covers 2,492 square kilometres, aim to support local health structures in addressing increased patient needs. While the majority of MSF’s patients are Rohingya, comprehensive mental healthcare services are also available for Bangladeshis.
Enduring social stigma
Among both communities, mental health remains poorly understood. Most patients at MSF’s health facilities exhibit visible signs of psychological stress and trauma. Many others suffer from depression, post-traumatic stress disorder, schizophrenia and psychosis, which go virtually unnoticed by their community.
Patients with visible signs of psychological distress are said to be possessed or under the influence of black magic. The Rohingya community, excluded from healthcare for decades in Myanmar, often resort to traditional healers due to either cultural affinity and beliefs, or lack of trust in healthcare providers in the camp.
“Many patients are referred to mental health counsellors only when they come to seek medical treatment for physical ailments in our health facilities,” says Tanya Morshed, an MSF psychotherapist and clinical social worker. She is responsible for strengthening mental health awareness activities among the communities in Kutupalong and Balukhali camps.
“Psychiatric patients who display aggressive behaviour are often chained due to fears and misconceptions around mental illnesses. Neglect of basic needs of food and cleanliness, and isolation can result in further deterioration of their condition,” says Morshed. “Those without visible signs endure.”
The most vulnerable, according to Morshed, are those who suffered sexual violence, either in Myanmar or in the refugee camps in Cox’s Bazar. For MSF, sexual violence is an emergency that requires immediate medical attention. Stigma around it, nested in patriarchal attitudes, increases the risk of long-term psychological damage. Morshed says children born from rape are often abandoned and are shamed by their own community.
“We need to pay attention to the intergenerational consequence of this crisis,” she adds.
Morshed observes that those who survived sexual violence, whether in Myanmar or in the refugee camps in Cox’s Bazar suffer lasting impacts of psychological trauma. “Seeking mental health treatment is often avoided due to fear of shame, patriarchal attitudes, as well as stereotypes around mental health issues,” she explains.
Community mental health educators visit patients and families to build psychosocial knowledge on the importance of mental healthcare and the destabilising effects of stigma. Living in cramped spaces in unhygienic conditions, and facing an uncertain future has a severe and lasting psychological impact. How can MSF alleviate the mental health conditions of our patients?
“Comprehensive mental health treatment is integrated into all our health facilities in Bangladesh. We treat all patients irrespective of their identity as Rohingya or Bangladeshi,” says Morshed. “Compassion is not complicated. For me, preventing one suicide, helping just one person cope with these challenging circumstances is making a difference. I just try to listen.”
Patients’ isolation and loneliness is another challenge for MSF’s mental health teams. Their inability to contact their families in Cox’s Bazar or Myanmar due to restrictions on movement or telecommunications can worsen existing conditions.
MSF teams tackle the stigma and isolation faced by patients by building trust and solidarity through psychoeducation activities. Community mental health educators (CMHEs) with similar religious and cultural affinities are key in building trust and awareness of mental healthcare among patients, caregivers and community leaders.
Patients and families often abandon mental health treatment, as counselling and medication can take time to take effect. CMHEs help ensure patients continue medication and follow up on psychosocial sessions. Mental health teams, composed of CMHEs, counsellors, psychologist supervisor and psychiatrists ensure each patient has a specialised treatment plan.
The loudspeaker at the Jamtoli mosque crackles again. Imam Majeed repeats his message, optimistic that people will follow his advice. Patients, caregivers, community leaders and MSF teams are together in ensuring trauma and deprivation does not come to define the lives of those seeking mental healthcare in Cox’s Bazar. But is there hope?
“Most of my young patients are scared of men in uniform, as they witnessed violence perpetrated by either the Myanmar army or police,” says Iyer. “When the children improve, they are able to recount their experiences without trembling or urinating in their clothes. Isn’t that hope?”
MSF provides comprehensive mental healthcare, including psychiatric care, across all our facilities in Cox’s Bazar. Between August 2017 and September 2019, we provided 38,904 individual and 55,170 group consultations. Additionally, in collaboration with the Ministry of Health and Family Welfare (MoHFW), we have established mental health services in Ukhia Upazilla Health Complex since mid-2017. It is one of the first MoHFW facilities with decentralised mental health activities in a health complex. Here, MSF counsellors screen patients for mental health issues, provide individual and group counselling sessions and refer severe cases to our Kutupalong Field Hospital.