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COVID-19 AND MIGRANT WORKERS:
CLINICAL PSYCHOLOGISTS’ VIEWPOINTS
ASIMA MISHRA and DR. NEHA SAYEED
Department of Clinical Psychology, Central Institute of Psychiatry, Ranchi
Introduction
Coronavirus disease has achieved pandemic status worldwide and people everywhere are in a state of constant fear and deep anxiety as there is no final word on how long this pandemic will last. People are now being told to make up their minds to live with this virus for a long time without any clarity. The worst affected are the migrant workers. Mental trauma and the threat of infection are now very firmly etched into the minds of people which ultimately has an adverse impact on their mental health. Long periods of isolation and lack of access to resources also may have a negative impact on mental health and psychological functioning. Various studies are being conducted to explore the long-term impact of COVID-19 on mental health. It is essential for physicians and mental health providers to have open conversations about the importance of mental health and to encourage people to seek help (Singh, 2020).
There are around 100 million internal migrant workers in India. Most of them are daily wage labourers who travel from various states like Uttar Pradesh, Bihar, Jharkhand, Odisha, West Bengal and other states in that region, to perform unskilled or semi-skilled jobs and are currently facing major economic fluctuations due to the sudden lockdown ( Hazarika, 2020). By the time the country was put on lockdown, the workers had already started facing a decline in their income due to social distancing and isolation. Amidst all the chaos, confusion, uncertainty and fear spreading across the country because of COVID-19, the migrants are trapped in an extremely upsetting situation which has brought the spotlight on invisible labour migrants.
The International Labour Organisation (2020) has highlighted that, migrant workers are experiencing the worst of the economic crisis as prices of basic hygiene products, including detergents/soaps/sanitizers for personal safety are rising rapidly, as well as food items, because of which many workers are unable to afford them. As businesses are now required to close, many employers are terminating the employment of migrant workers without prior notice or have stopped paying salaries. Panic and fear of the COVID-19 virus is increasing prejudice and abuse against migrant domestic workers. The economic crisis combined with COVID-19 is increasing pressure on lower-income families to pay salaries, cover expenses for food, clothing and medicines, or provide a suitable private room in the household.
This article is a clinical observation based on the review of existing literature on mental health symptoms and interventions relevant to COVID-19 pandemic along with review of various news articles highlighting the plight of the migrant workers. The articles which were reviewed focused on the psychosocial issues of migrant workers and what steps are essential to manage these issues.
Mental Health and Migrants
Widespread outbreaks of infectious disease, such as COVID-19, has always been associated with psychological distress and symptoms of mental illness (Bao et al., 2020). Under normal conditions, migrant workers have a high burden of common mental disorders (e.g., depression) and a lower quality of life than local populations. Many studies across the globe have consistently found a positive association of common mental disorders with adverse circumstances such as poverty, inequality, and financial debt. Firdaus (2017) in his study found that prevalence of poor mental well-being was higher among those who were single/widowed/separated/divorced, unskilled, unemployed, daily wager, illiterate and older in age. It was also found that poor mental health was in turn associated with poor housing, educational and medical facilities. These factors lead to poor social support, feeling of insecurity and adjustment issues. Migrant labourers due to their unique and disadvantageous position are particularly vulnerable to all these risk factors.
Migration often brings with it stress, strain, and risk factors such as poor medical care, separation of family and children as well as other relatives. It also includes homelessness, lack of food and water, xenophobic attacks, poor education, perceived and experienced discrimination, and a high risk of death and injury. Furthermore, social factors, like cultural bereavement, culture shock, social defeat, as well as a discrepancy between expectations and achievement, and acceptance by the new nation can also affect adjustment. Further risk factors in new communities can include social exclusion, stigma, and discrimination. According to Firdaus (2017), the migrants feel unwelcome by their host societies and perceive cultural differences such as language, traditions, food habits as the main reason hindering development of social networks outside their own communities. Cantor-Graae and Selten, (2005), reported that chronic experience of social defeat was related to poor mental health and risk of psychosis in migrants.
Henssler, et al., (2020) found that there is increased risk for the manifestation of schizophrenia and related non affective psychosis among first- and second-generation migrants. The study suggested that increased rates of psychotic experiences in migrant workers are due to experience of discrimination and social exclusion. Petit, et al., (2001) reported that the risk of developing dementia among certain groups of migrants is higher in comparison to people who grew up in the host country. The authors discussed that cardiovascular comorbidity may be responsible for the higher rate of dementia. However, there seems to be a lack of screening tools for the educationally disadvantaged migrant population as highlighted by Nielsen and Waldemar (2010). Systematic reviews have also found high prevalence of PTSD among the migrant workers. Morina et al. (2018), reported that the highest prevalence of psychiatric disorders was registered for post-traumatic stress disorder from 3% to 88%, depression from 5% to 80%, and anxiety disorders from 1% to 81% in refugees and internally displaced persons after forced displacement. This pointed out that there is an urgent need for large-scale interventions that address psychiatric disorders in refugees and internally displaced persons after displacement. It was also found that greater exposure to pre-migration traumatic experiences and post-migration stress were the most consistent factors associated with all three disorders. Importantly, a poor post-migration socio-economic status was associated with depression.
On the other hand, Giacco, Laxhman, and Priebe (2018) observed that in the first years of resettlement, only PTSD rates were higher in refugees as compared to host country populations. However, after five years of resettlement, rates of depressive and anxiety disorders were elevated. Traumatic experiences during migration may explain the high rates of PTSD, while poor social integration and difficulties in assessing care may contribute to higher rates of mental disorders in the long run.
Psychological Impact of COVID-19 on Migrants
Mahanirban Calcutta Research Group (MCRG, 2020) have written extensively about the issues the migrant workers are facing in this economic crisis due to COVID-19. The sudden announcement of lockdown for twenty-one days with a notice of less than four hours created havoc to the labour migrants in different parts of the country. Since the lockdown, there were distress calls from stranded migrant workers for food and cash from various parts of India. There is much agony, hunger, trauma -- physical and psychological -- and a desperation to return home. Migrant labourers from different parts of India even marched back hundreds of kilometres carrying their belongings to reach home in different parts of the country. Along with bearing the physical exertion, they had to shield themselves from continuous assault from the police which in many places lathi-charged and humiliated them. Nonetheless, the migrant labourers, having no other options, continued their long marches which, at times, even resulted in deaths of many due to hunger, dehydration, and exhaustion. More than 20 people have lost their lives in this mayhem since then (MCRG, 2020). They faced stigma from their neighbours since they were seen as carriers of the coronavirus, faced ostracization which led to clashes and hiding the truth about returnees. Similar struggles were reported by Knoll & Bison, (2020) and Modak, (2020).
The ongoing reverse migration of day workers to their villages is likely to accelerate the deterioration of mental health. Due to the sudden influx of migrant workers and at-risk farming community, rural India may be particularly susceptible to suicide according to Nelson Moses of Suicide Prevention India Foundation (Krishnan, 2020).
Since the lockdown, the media had highlighted the plight of the migrant workers in different parts of the country. In Bareli of Uttar Pradesh, hundreds of migrants including women and children were forced to take chemical baths as disinfectant (MCRG,2020). While in the Siwan district of Bihar the migrants who managed to reach the district town of their home were put in very small space under an iron gate in a very infectious condition. They were rescued the next day and were put in trucks to take them to their respective panchayats where corona isolation centres were located. In shelters with high concentration of migrant domestic workers and few protective measures, there is often a significant risk of infection. In most places, the migrant labourers were stuck in makeshift camps, with poor infrastructure and inadequate food supply. There has also been unrest among the workers over rumours on the resumption of train services and complaints about the food in Mumbai and Surat. Their predominant experiences were hunger, hopelessness and fear about if and when this nightmare would end (Mahanirban Calcutta Research Group 2020). For them it appeared that it is more of a problem of basic needs not being met, leading to anxieties.
Intervention strategies that need to be adopted
It appeared that migrant people will continue to have an elevated need for mental health care, but simultaneously have less access to it. Reasons for this gap may be due to stigma and shame regarding mental illness, cultural beliefs, lack of language proficiency as well as financial constraints. Furthermore, real economic barriers and perceived social consequences could impede service seeking because they may often lack health insurance (Firdaus, 2017).
It is likely that the number of migrants and refugees will continue to increase over the years and health care services have to be prepared for them. Adequate resources need to be given to health care professionals and policy makers to meet the needs of the migrant population. Collecting more information about the impact of culture on key aspects of a migrant patient’s clinical presentation may help provide better care. Furthermore, the cultural competence of all professional staff and regular use of cultural mediators could be very useful to access health care services and reduce the key barriers to service access and use. Improving the institutional, cultural competence could increase the quality of care at a systemic, organizational, and institutional level. Therefore, cultural competence training for all professional staff and initiatives to facilitate institutional, cultural competence should be implemented to increase the utilization of mental health services (Schouler-Ocak, 2020).
COVID-19 outbreak and consequent nationwide lockdown have resulted in significant deterioration in all the social determinants of health. Loss of income and jobs, insecurities, and social isolation are increasing and are likely to deteriorate the mental health of migrant populations which may worsen in post lockdown periods. There are high chances of increase in suicide considering the poor utilization of health services in general and mental health services in particular. Faruqui, director of Centre for Evidence-based Policy, Practice and Interventions (CEPPI) at Oxford stated that, “The evidence-based approach to diminishing the effects of these problems is to carefully deliver psycho-social interventions that operate on the feedback of standardised outcome measures. The interventions should be exercised as primary (directed towards all Covid-19 patients or lockdown affected), secondary (intended to reduce existing risk), or tertiary (aimed at improving outcomes for affected people with mental issues in Covid-19 context) (Khan, 2020).” They also reported that the COVID-19 period provided opportunities to explore new ways and methods for mental health professionals such as establishment of wider public e-mental health approaches, a shift towards digital, novel interventions that are mainly powered by theories of behaviour change and prosocial behaviour (Khan, 2020).
Role of mental health professionals
Banerjee (2020) identified six important roles for mental health professionals during this period and suggested that educating the public about psychological effects of a pandemic, motivating to adopt health promotion strategies, integrating mental health into available health care, teaching coping strategies, empowering patients and caregivers and providing mental health care to the healthcare workers are essential. From our perspective, for providing more specific therapeutic strategies, it is essential to develop teams of qualified psychologists to address emotional distress and training community health personnel in mental health care. Using online platforms to assess mental health of public and developing materials may be considered. Apart from this, providing online counselling and self-help services and using tele-psychiatry and telemedicine services are essential (Joshi, 2020; Amulya, 2020). However, the most important aspect is to make online mental health services accessible to everyone, particularly, the individuals in lower socioeconomic strata.
The Government of India (MOHFW, 2020) has released detailed guidelines to deal with the psychosocial issues of migrants who have been impacted by the nationwide lockdown to deal with the spread of the coronavirus disease. Orders are in place to treat migrant workers with dignity, respect, empathy and compassion by listening to their concerns patiently and understanding their problems and to recognise specific and varied needs for each person/family. As per the guideline, it is essential to provide them with all possible information and make them stay in their present location since mass movement could greatly and adversely affect all efforts to contain the virus. Trying to understand their issues and reminding them that it is safer for their families if they themselves stay away from them, is essential. Instead of reflecting any mercy, seeking their support in the spirit of winning over the situation together is important.
COVID-19 has led to a multifaceted response from mental health professionals and mental health is now clearly being taken into consideration at all levels - be it general population, health care workers or the vulnerable populations. The long-term impact of COVID-19 on mental health may take months to manifest and managing this impact requires the effort from the health care system at large, as it happened in the case of SARS (Maunder, 2009). In our country where the mental health infrastructure is less developed, the impact is likely to be severe and further research is necessary to assess the scope of the pandemic (Duan and Zhu, 2020). Identifying the groups of people who are at high risk for psychological morbidities will be the first step at providing early intervention. Those people who are in isolation centres in hospitals or the migrant workers who are quarantined in shelters are prone to increased risk of psychological issues as they are deprived of social support and uncertainty of their return to their homes, and particularly demand emotional support. Therefore, it is of utmost importance to research on vulnerable populations like children, those in rural areas with poor access to health care and those belonging to economically deprived.
Strategies for Intervention
There is a need to develop interventions which are time limited, culturally sensitive and can be taught to healthcare workers (Liem et al., 2020). These interventions need to be tested so that the information regarding effective therapeutic strategies can be disseminated among those working in this field. Since there is a shortage of staff, all physicians, practitioners and emergency staff need to proactively screen for psychological issues. Taking advantage of the digital era, interventions should be planned and designed to make them easily deliverable. Online psychotherapy through video conferencing applications can be used. However, to meet the needs of the nation it would be necessary to provide online or smartphone-based psychoeducation to provide information regarding the virus, promote wellness and initiate psychological interventions like cognitive behaviour therapy and mindfulness-based interventions. Challenging cognitive bias of individuals who exaggerate the risk of contracting the virus and teaching them behavioural strategies of relaxation to reduce anxiety and schedule activities to combat depressive feelings can be taken up. Teaching stress management strategies and instilling positive coping is important. Helping individuals in mindfulness meditation also may help in alleviating stress and anxiety (Ho, Chee & Ho, 2020).
Another challenge is to relay accurate information and evidence based health practices to the public. Minimising fake news and providing safety tips on basics like maintaining hand hygiene, mask wearing and physical distancing are needed. Coping with the current situation emotionally through positive mindset and relaxation/breathing techniques have to be promoted. These can be done through video clips and images that are easily understood. The Ministry of Health and Family Welfare (MOHFW, 2020) has several videos, audio-visual aids as well as advisories for the behavioral health of every individual under the campaign ‘Help us to help you’ on their website. There are practical tips to take care of one’s mental health during the lockdown and an audio-visual aid on managing stress and depression in the website. The Ministry has also provided measures on dealing with social isolation, emotional problems, emotional issues which may occur after recovery, ways to recognize mental health problems in beloved and caring for persons with mental illness (Saini, 2020).
Several mobile applications like Arogya setu by Govt. of India, COVID-19 Feedback by Indian Ministry of Electronics and Information Technology, SAHYOG app by survey of India have been launched to help in keeping the public updated and help in self evaluation and contact tracing as well. Several state governments have also developed apps like COVID- 19 quarantine monitor-Tamil Nadu, COVA- Punjab and Test yourself Goa (Geospatial world, April 2020,).
Integrating community resources into the health care system will also help in reaching out to a wider population (Ho, Chee & Ho, 2020). This serves to strengthen the community’s mental health resilience and reduce the possibility of developing psychiatric morbidities. Several premier mental health institutes of our country like NIMHANS, CIP, IHBAS and others in collaboration with various NGOs have taken up this challenge and are running a 24/7 mental health helpline since lockdown. Organizations like Indian Association of Clinical Psychologists (IACP), regional psychology associations and Indian Psychiatric society (IPS) have prepared and widely distributed lists of professionals providing pro bono services through telephonic and video calls through which several distress calls have been answered (Kumar, 2020).
Conclusion
The coronavirus emergency is rapidly evolving. Nonetheless, we can more or less predict the expected mental/psychological health consequences of the most vulnerable populations. It is essential for mental health professionals to provide necessary support to those exposed and to those who deliver care. In order to minimise the impact, providers should promote positive stress management strategies and normalise the experience of anxiety and fear during this time. It is imperative that mental health professionals be part of the task force for COVID-19 to advise the government on mental health policies and psychological interventions. Hospitals and community workers are now working individually to conduct psychological intervention with limited interaction with each other. If they collaborate with one another through training and case discussions, our limited resources can be well utilised. Training the community personnel at this time can facilitate better identification as well as management of distress. This pandemic has taught our country to be more medically prepared to deal with future outbreaks, have better equipment and infrastructure. However, the psychological impact that this outbreak has caused should not be ignored. The pandemic has highlighted the need for mental health and psychological intervention to the nation and we need to strengthen this particular aspect in order to win this war with COVID-19.
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