|Year : 2019 | Volume
| Issue : 2 | Page : 181-186
Mental health of Rohingya refugees and asylum seekers: case studies from Malaysia
Xavier Pereira1, Sharuna Verghis2, Cheng Kah Hoe3, Asma Binti Zahir Ahmed4, Shasvini Naidu Nagiah5, Leo Fernandez6
1 Director, Health Equity Initiatives, Kuala Lumpur, Malaysia; Associate Professor, Taylor’s University School of Medicine, Malaysia
2 Director, Health Equity Initiatives, Kuala Lumpur, Malaysia; Senior Lecturer, Jeffrey Cheah School of Medicine and Health Sciences, Monash University, Malaysia
3 Program Coordinator, Health Equity Initiatives, Kuala Lumpur, Malaysia
4 Community Health Worker, Health Equity Initiatives, Kuala Lumpur, Malaysia
5 Patient Manager, Health Equity Initiatives, Kuala Lumpur, Malaysia
6 Consultant, IMS, Health Equity Initiatives, Kuala Lumpur, Malaysia
|Date of Submission||23-May-2019|
|Date of Decision||26-Aug-2019|
|Date of Acceptance||17-Sep-2019|
|Date of Web Publication||29-Nov-2019|
Health Equity Initiatives, 26-1A, Jalan Vivekananda, Brickfields, 50470 Kuala Lumpur
Source of Support: None, Conflict of Interest: None
Rohingya refugees are one of the oldest and largest asylum-seeking populations in Malaysia. Yet, there is a dearth of literature in relation to this population and their mental health. Through case studies, this paper seeks to add to the emerging body of knowledge on the Rohingya. These case studies highlight the unique factors which contribute to mental ill-health among them. It also seeks to identify mental health and psychosocial support strategies that are currently being implemented to address the mental health needs of the Rohingya in Malaysia, the challenges encountered and possible ways forward.
Key implications for practice
- The importance of psychological and psychosocial interventions beyond pharmacotherapy.
- The need for an multi-disciplinary approach.
- The importance of cultural sensitivity and cross cultural communication.
- The role of advocacy in complementing clinical interventions in developing sustainable solutions to addressing the mental health needs of the Rohingya.
Keywords: Malaysia, mental health, psychosocial support, Rohingya
|How to cite this article:|
Pereira X, Verghis S, Hoe CK, Ahmed AZ, Nagiah SN, Fernandez L. Mental health of Rohingya refugees and asylum seekers: case studies from Malaysia. Intervention 2019;17:181-6
| Introduction|| |
Of the two million Rohingyas dispersed across Asia currently, about 90,206 are registered with the United Nations High Commissioner for Refugees (UNHCR) in Malaysia (UNHCR, 2019). Additionally, a significant number are yet to be registered. UNHCR estimates the number of unregistered to be between 8,000 and 10,000. [Table 1] provides the age and sex disaggregated numbers of Rohingya refugees and asylum seekers registered with UNHCR Malaysia at the end of April 2019.
The earliest arrival of the Rohingya in Malaysia, concomitant with the first wave of forced displacement from Myanmar, was in 1978 by land via Thailand (Human Rights Watch, n.d.). Since then, successive waves of Rohingya refugees arrived by land via Thailand as well as by boat, with the latter phenomenon gaining international attention in 2009, 2012 and prominently during 2015 when a few thousand were stranded in the Andaman sea between Bangladesh and Malaysia. An estimated 170,000 people are reported to have travelled by sea between 2012 and 2015 from Myanmar to Thailand and Malaysia, generating a revenue of about USD 50–100 million to people smugglers and traffickers (UNHCR, 2015). During 2015, the finding of 139 mass graves of Rohingya victims in 28 suspected human-trafficking camps on the Malaysia–Thailand border were testimony to these perilous journeys of the Rohingya fleeing persecution and inter-communal clashes in Myanmar (Jay & Povera, 2019).
While Malaysia’s immigration law does not distinguish between refugees, asylum seekers and undocumented migrants and it lacks a domestic framework of legal recognition of the refugee population as a whole, it has allowed refugees to reside in the country since the 1970s. However, refugees lack the formal right to work, their children remain stateless, and access to healthcare remains problematic. The precarity of their legal status and fragility of livelihood leave refugees particularly vulnerable to exploitation creating unique health risks, including mental health risks (Health Equity Initiatives, 2011), with these conditions being applicable to the Rohingya too. However, like all refugees, the Rohingya are not a homogenous group. The duration of residence in the country, family emplacement in Rakhine state in Myanmar and socio-economic status have been found to influence their ability to access social support and resources within their community and in the host society, and to navigate basic services such as healthcare (Verghis, 2013).
| Health Equity Initiatives|| |
Health Equity Initiative (HEI) is a Malaysian non-profit, community-based organisation and runs an integrated mental health programme covering prevention, treatment and rehabilitation services and using the mental health and psychosocial support (MHPSS) approach (Inter-Agency Standing Committee (IASC), 2007), with activities comprising of: (i) a community-based mental health programme including an annual training of refugees as community health workers (CHWs) in mental health, advanced professional development of CHWs on mental health, community-based mental health screening, and mental health promotion; (ii) psychiatric and psychological interventions; (iii) psychiatric treatment adherence support; (iv) mental health rehabilitation; (v) facilitated support groups; (vi) psychosocial support services; (v) and research-driven advocacy. It also hosts a health and human rights internship programme for medical students. The HEI mental health team consists of psychiatrists, clinical psychologists, counsellors, social workers, nurses and CHWs.
| Methods|| |
This paper is based on a review of case files of Rohingya patients attending HEI’s mental health services (MHS). Additionally, field notes of HEI’s team members from outreach activities and home visits were included in the review.
Overall, out of a total of 384 refugee patients from Myanmar, Sri Lanka, Afghanistan, Syria, Yemen, Iraq, Iran, Somalia and Sudan, in HEI’s MHS, there are 66 Rohingya patients, of whom 42 are men and 24 are women, with ages ranging from seven years to sixty-six years and the average age being 31. Based on the predominance of patients presenting with mood disorders and mood disorders with comorbid anxiety disorders and/or stress and trauma-related disorders, 30 patient files fitting this diagnostic profile were purposively selected. These included fifteen patients with a diagnosis of only mood disorders, seven with mood and anxiety disorders, six with mood and stress and trauma-related disorders and two with mood, anxiety and stress and trauma-related disorders as per DSM V. From these 30 files, 24 patient files were further selected, excluding children and those patients who had been assessed upon intake but who had not yet obtained their psychiatric appointment.
Detailed case studies were compiled of the files of the 24 Rohingya patients and examined in tandem with the field notes of home visits to patients and community outreach notes. Typically, the patient intake form records presenting problems, history of presenting problems, past psychiatric and medical history, family history, antenatal and birth history, childhood, education, migration, work and marital and sexual history. Additionally, preceding the physical and psychiatric examination information, information pertaining to socio-economic and cultural-religious contexts, psychosocial support and substance use histories are also documented. Subsequent notes include progress made by the patient, referrals for medical and psychosocial support and any other material assistance.
The above qualitative data were thematically analysed and dominant themes were identified through systematic sorting of data, labelling ideas and phenomena as they developed, with emerging trends examined against existing literature. Coding and analysis were iterative and by hand.
Patients obtaining services at HEI are asked if they would consent to their data being used in an anonymised form for educational and advocacy purposes. Informed consent forms are available in all the languages of the patients. In the case of the Rohingya patients, because the consent forms are in Myanmar language (given the absence of a written script for Rohingya language), the Rohingya CHW explains the contents of the form in Rohingya language. Patients are informed that they could choose to pass over the process and not provide consent with no consequences to obtaining services. All patients whose files were included in this review provided consent to the use of their data.
| Case Studies|| |
Owing to limitation of space, a full qualitative analysis of the 24 case studies cannot be presented. Thus, excerpts from four of the 24 case studies were selected for discussion in this paper. These four case studies can be considered representative and illustrative of the dominant themes which emerged, namely, events associated with onset of symptoms, stress and trauma of journeys of flight, stressful experiences of detention, access to treatment and treatment adherence, somatic symptoms of anxiety and depression and unique challenges of patients who are single women.
In [Table 2], among the 24 patients that were selected for this review, 18 were male and 6 were female. The average age was 32 for both male and female patients. Almost half were single while close to half were married, with the two widowed and one divorced person being women. The majority were referred by family and community members which could be indicative of a growing awareness of mental health problems in the community and/or the burden of care associated with support to family/community members with mental health problems and the need for solutions in such a situation.
Case study 1 – SH
SH is a 23-year-old Rohingya man who is being treated at HEI for major depressive disorder since 2017. He was referred by UNHCR. He arrived in Penang, Malaysia, by sea from Myanmar in 2012 because of fighting in Rakhine state. The journey by sea was very stressful. He travelled in a boat with 113 others. He was not given any food or water throughout the ten days of the journey and the smugglers even threatened to throw him overboard when he vomited.
When the boat docked in Penang, he was arrested and detained for twenty-seven days, while the smugglers escaped. He claimed that he became depressed during detention. It was a humiliating and stressful experience wherein those arrested were stripped naked and laughed at. He claimed that during his incarceration a fellow Rohingya man was abused by other detainees. He was released with the assistance of UNHCR. Upon arrival in Kuala Lumpur, he was placed with a Rohingya family by UNHCR. He reported that the man of the family physically abused him, brought him to an empty warehouse, tied his hands and feet and burnt his chest with cigarette butts. These burn marks were visible at the time of intake.
He was observed to have a change of behaviour since then and became aggressive. He complained of experiencing physical pains (headache and ‘inner bone pain’). He also had physical symptoms of palpitations, tremors and sweating. He reported sadness with crying episodes since arriving in Malaysia.
He was admitted to a public hospital. A diagnosis of major depressive disorder with psychotic features and anxious distress as per DSM V was made in HEI. Psychotic features included mood congruent hallucinations and delusions. Symptoms of posttraumatic stress disorder (PTSD) were not found. He was treated with an antipsychotic and an antidepressant. Upon discharge, UNHCR placed him in a shelter and referred him to HEI for treatment because he was unable to afford follow-up treatment at the public hospital. He had reportedly been admitted to hospital many times by UNHCR.
He was later moved to live with a family. The staff of HEI made a home visit to undertake a psychosocial assessment and found SH’s home environment to be supportive. HEI also made contact with the patient’s family members in Myanmar. HEI’s CHW kept in constant contact with him.
Other psychosocial interventions included treatment adherence support, psychoeducation and job placement. SH was unable to maintain a stable job. Some of his employers did not pay him for the work he had done.
He was on regular follow-up treatment at HEI and his psychotic symptoms gradually subsided. He is currently still on antidepressant treatment. He is less depressed and anxious. Current psychosocial stressors include lack of finances and difficulty in acquiring a stable job.
Case study 2 – NH
NH, a 40-year-old Rohingya refugee, referred by the community, was a teacher in a religious school in Rakhine State, Myanmar. He fled to Malaysia after the mosque he was teaching in was closed down and he was threatened by the army. He was also physically assaulted in a separate incident which made him fear for his life.
In 2012, NH was smuggled into Thailand in a boat. He was then driven to the Malaysian–Thai border in a car. He said that both the journeys were very stressful. He was not provided with food throughout the journey. He had been residing in Kuala Lumpur from 2012 to 2016.
In 2016, NH was arrested and detained in Malaysia for sixteen months. He claimed that he was physically abused in detention. He reported experiencing symptoms of depressed mood and anxiety since the period in detention. He also complained of head ache, body ache, twitching of muscles, back pain, neck stiffness and burning sensation over his feet since detention. He said that he was unable to work because of the body pains and felt guilty because he was unable to help his family in Myanmar.
He was seen in HEI in February 2019. He was diagnosed with major depressive disorder and Generalized Anxiety Disorder, and his Beck’s Depression Inventory (BDI) and Beck’s Anxiety Inventory (BAI) scores indicated severe depression and moderate anxiety. He was screened for PTSD using the Impact of Events Scale – Revised (IES – R). The score of 17 was not indicative of PTSD. The antidepressant, mirtazapine, was prescribed, and he was taught relaxation exercises (breathing relaxation exercises and muscular relaxation exercises) and provided psychoeducation. After about six weeks of treatment, he reported better sleep and appetite, and being less depressed, anxious and irritable. His aches and pains also reduced.
Other than headache and body ache, he complained of tingling sensations and numbness of his upper limbs and lower limbs since the abuse in detention. The psychosocial support team of HEI explored for medical causes of these symptoms and referred him for further assessment. X-rays of the spine revealed cervical spondylosis and spondylolisthesis.
Case study 3 – AS
AS, a 36-year-old, is a Rohingya lady who was referred to HEI by the Buddhist Tzu Chi Free Clinic for symptoms suggestive of anxiety and depression.
She fled to Rakhine state in 2015 with her husband and five children after being beaten by the Myanmar army who finally confiscated the family property, including the land they were living on. They were smuggled in a boat ferrying about 300 people. Food and drink were provided to them. After they arrived in Thailand they were hidden in a forest by an agent* (*smuggling/trafficking syndicate) for about six days. They paid this agent for his services though she was unaware of the amount her husband paid. AS and her children were then transported by car to the Thai–Malaysian border and walked across the border into Malaysia. They travelled to Penang and stayed there for a month. The family left Penang for Kuala Lumpur when her husband found a job in Kuala Lumpur.
In Kuala Lumpur, she sought treatment for somatic symptoms at the Buddhist Tzu Chi free clinic for refugees. The main symptom was pain of both legs associated with change of sensations of the feet like numbness and warmth. Examination and investigations excluded a physical cause for these symptoms.
Some of the pertinent factors contributing to her mental health issues were: financial challenges, the irregular employment of her husband who was the sole bread winner for the family and her physical symptoms which were not improving with treatment.
Upon assessment in HEI, she had mood changes and other symptoms suggestive of depression and anxiety. These symptoms began around the same time that she started experiencing pain of both legs. She was prescribed an antidepressant, taught breathing and muscular relaxation exercises and provided psycho education. The patient however defaulted treatment after several follow up visits. She found it difficult to understand that her somatic symptoms were linked to her anxiety and depression.
Case study 4 – AB
AB is a 35-year-old Rohingya woman, who was married at the age of 17. She was referred by the community. In 2013, she fled to Rakhine state after her family members were arrested and community members killed by the army. They travelled by boat to Thailand and were physically abused by the smugglers when they asked questions. Due to an incident of violence, she and her son were separated from her husband during the journey. Upon reaching Thailand she and her son with some others were stranded in a forest for a month where they survived by eating leaves and fruit. She witnessed fellow asylum seekers like herself die one by one in the forest where they were buried. She was later reunited with her husband who arrived before them in Malaysia. The husband who had arrived earlier in Malaysia paid an estimated USD 4,239 to have her and her son released by the human smugglers/traffickers. Her husband passed away in 2015 after having sudden chest pain. She claimed that his passing was very hard on her as she had to continue her life as a single mother, and she did not have any other social support apart from her husband.
She complained of palpitations with no known trigger, lasting ten to twenty minutes each time and occurring every two to three days. She also claimed the palpitations were associated with tremors, choking sensations, profuse sweating and tingling sensation of the whole body. She stated that she had sought medical treatment for her palpitations but it was not helpful. She stopped doing work because of the palpitations and stays home most of the time. She reported that she developed sadness and crying spells after the palpitation. She also experienced other physical symptoms like dizziness, body ache and headache. She reported poor sleep, loss of appetite and loss of weight. She was diagnosed with major depressive disorder and panic disorder. She was provided pharmacological treatment and supportive counselling.
| Discussion|| |
The onset of symptoms in all the cases coincides with critical life events that were either traumatic and/or stressful. Prominently, patients in the above case studies and others in the cohort of Rohingya patients who had been detained in Malaysia reported that their symptoms began during this time of detention where they had experienced abuse. These narratives align with the adverse mental health impacts of immigration detention discussed in the literature (Fazel & Silove, 2006; Silove, Austin, & Steel, 2007). Additionally, the case studies also highlighted the perilous journey by boat and land, organised by human smugglers/traffickers and their association with trauma and stress leading to physical and mental health problems, and even death, as witnessed by AB. The discovery of mass graves in Wang Kelian (Jay & Povera, 2019) epitomizes such avoidable morbidity and mortality and requires solutions engaging with broader national and regional processes, beyond the conventional MHPSS framework that is focused on the early stages of emergencies, usually with mass displacement (IASC, 2007). This framework is less suitable for protracted, urban refugee situations.
A key predicament faced by urban refugees are the barriers to accessing basic services because of the lack of legal status. Accessing services including health care, in most urban refugee settings such as Malaysia, is inextricably linked to the salience of legal identity and legal documents. Yet, most countries in the south and southeast Asia currently lack national frameworks of protection for refugees and asylum seekers. As a result, refugees and asylum seekers in these countries are deemed irregular migrants, denied the formal right to work, and in countries like Malaysia, prohibitive user fees are imposed on non-citizens at healthcare facilities. Such a context creates inimitable barriers to accessing health care services, even when these are available, and underscores the need to review policy frameworks that are currently being applied to urban refugees.
For example, UNHCR referred NH to HEI because he could not afford treatment in public hospitals. The regulatory framework related to healthcare and non-citizens actively prevents the access of non-citizens including refugees and asylum seekers to public hospitals. Non-citizens in Malaysia are required to pay ‘foreigners’ rates’ at government hospitals which are substantially higher than what citizens pay. While healthcare in public hospitals is available at a discounted price to UNHCR-recognised refugees and asylum seekers, it is unaffordable (Balasundaram, 2011). There is evidence that accessing healthcare in public hospitals has led to catastrophic health expenditures for refugees in Malaysia (Verghis, 2013). In this context, HEI’s provision of outpatient MHPSS services such as job placement, home visits, continuous contact by the CHW over the telephone and, importantly, treatment adherence support enabled NH to reduce the need for hospital admission and access maintenance treatment. Such a multi-pronged strategy of different levels of intervention targeting different psychosocial and treatment needs reinforces the importance of the MHPSS interventional framework (IASC, 2007). It also emphasises the importance of community-based strategies to ensure treatment adherence and treatment completion in the urban refugee context. However, it exposes the limitations of UNHCR’s urban refugee policy which advocates against establishment of separate and parallel services and integration into existing services (UNHCR, 2009).
On the other hand, existing regional frameworks such as the Bali/ASEAN processes tend to focus on the securitisation of migration, although UNHCR in engaging with these processes has attempted to promote the ideas of rescue at sea, non-refoulement and addressing statelessness (Kneebone, 2016). With immigration focused laws in countries like Malaysia which penalise unauthorised entry, the absence of mechanisms for reception of asylum seekers, and the tri-fold ASEAN principles of upholding respect of state sovereignty, non-interference in the international affairs of member states and consultation and consensus which pre-empt any push back against Myanmar, the Rohingya bear the brunt of the army-led onslaught of the Myanmar government and remain at risk of developing preventable mental health problems.
Additionally, the predominant presenting symptoms in the persons in the cases described in this paper were psychological and physical symptoms of depression and anxiety. Many of the somatic symptoms as in the cases of SH, AS and AB were physical symptoms of anxiety and depression, with this phenomenon resonating with existing literature around Rohingya presentations of mental health conditions (Tay et al., 2018; Tay et al., 2019). Tay et al. (2018) also found that symptoms of distress were interpreted as physical symptoms or medically unexplained symptoms, also linked to spirit possession. Although many of HEI’s Rohingya patients do attribute their symptoms of mental ill health to spirits, the individuals in the above four cases did not do so. However, aligning with the literature (Tay et al., 2018) in the Malaysian case too, Rohingya refugees with mental health problems did not perceive the link between their physical and mental health conditions. In the case of NH, there were also physical symptoms possibly due to injuries sustained in detention. Such cases require further medical evaluation to rule out medical causes of accompanying physical symptoms.
The case of defaulting treatment by AS points to cross-cultural challenges of communicating about mental health problems with refugees and maintaining culturally safe services that bridge their world views and those of care providers. Working with the Rohingya population requires agencies to pay more attention to building their capacities in the provision of culturally sensitive MHS, especially recognising the absence of correspondence between Western defined diagnostic categories and concepts and conceptualizations and vocabulary used by the Rohingya to express mental distress (Tay et al., 2018). Finally, the case of AB, the widowed woman, puts the spotlight on the unique predicament of single-women-headed households. This is because the Rohingya community is not formally organised in the same way as other ethnic minorities from Myanmar in Malaysia. Previous studies have shown that often it is the immediate family which is the source of material support for the Rohingyas (Verghis, 2013). Within such a context, single-women-headed households experience unique challenges in meeting their basic material, social and psychological needs (HEI, 2019). UNHCR estimates that there about 182 registered single-women-headed households. The widowed and divorced Rohingya women patients of HEI stated that they had no social support. UNHCR provided them with assistance for a short period of time after which they had to fend for themselves and their children. They stated that because they did not know to read and write, they picked up jobs as street cleaners and sometimes begged when there was no food in the house. One woman said that she sent her 14-year-old son to work. However, he was arrested by the police and she experienced guilt and felt useless because she felt that instead of taking care of him, she was thrusting adult responsibilities upon him (HEI, 2019). This case demonstrates the vulnerability of sub-groups like single-women-headed households, the unique social determinants of their mental health and the importance of focusing on sub-groups such as single-women-headed households in examining the impact of mental ill health on the household among the Rohingya.
| Conclusion|| |
This paper highlights factors associated with the mental health problems of Rohingya refugees and asylum seekers in Malaysia and the challenges experienced by care providers. In doing so, it draws attention to a range of interventions required to enable Rohingya refugees to address their mental health problems. This includes the holistic framework of action posited by the MHPSS framework including pharmacotherapy, psychological interventions and psychosocial support, in addition to policy advocacy, and capacity building on cultural competency for agencies working with the Rohingya in order to develop sustainable solutions. Overall, more research is required to bridge the current information vacuum.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]