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Refugees Need More Than a Welcome Mat

Refugee children from Syria play outside the central registration center for refugees and asylum seekers in Berlin, Germany. (AP Photo/Markus Schreiber)

One of the greatest daily challenges in the nonprofit global health world is reaching patients — delivering care to people who live in regions that are tough to access, or where armed conflict puts up roadblocks. There are times, however, when the patient arrives at the doorstep.

In the last month, a flood of refugees has reached European shores. Among them are Iraqis, Syrians, and Sudanese fleeing war, Eritreans leaving behind human rights abuses, and Bangladeshis escaping poverty and more. The moment has triggered everyone from ordinary people in Iceland to the Pope to offer them shelter.

Yet while many empathize with the need for shelter and basic safety, the issue of pressing mental health needs is less widely recognized. Yet this too is important. Some refugees — like the father of drowned toddler Aylan Kurdi — have narrowly escaped death, lost family members or watched others die. Many others have endured trauma before leaving home. The compassionate response needs to include appropriate mental healthcare. Unfortunately, most research on psychological topics is done in the West and involves oversampling so-called WEIRD people (“white, educated, and from industrialized, rich, and democratic countries”). As non-Westerners in need of mental healthcare reach European shores, do we have the knowledge to help them?

Vikram Patel says we do. A psychiatrist affiliated with the London School of Tropical Medicine and Hygiene, he has been lauded for his work on advancing mental healthcare worldwide. And his innovations in India might be a key to assisting migrants in Europe now.

Patel says the question of generalizing Western findings to non-Western populations started his career: “I myself was a skeptic. Twenty years ago, for example, I seriously doubted the validity of depression in non-Western settings.” But after “years of empirical research,” he says, “I began to replicate findings … [in] places as different as urban Zimbabwe and rural India.”

Patel’s colleague, Harvard-trained anthropologist Alex Cohen, has written in The Lancet, “Until the past decade, education about mental health issues across the world was mostly confined to anthropology and transcultural psychiatry programs in which the object of study was, for the most part, variation in causal attributions, the presentation of states of distress, and traditional healing practices” — qualitative explanations, in other words, of cultural novelty, not universal phenomena. Nonetheless, Patel can point to the work of many researchers who have captured data on the prevalence of common mental disorders in the developing world. Today, those numbers exist for most countries, and mental health issues — particularly depression — are known to be among the most common health problems worldwide.

Critically, Patel has also found that people all over the world responded well to the same kinds of treatment his training in the U.K. had prepared him to provide: “Psychotherapy” — simply talking through problems — “can remain effective in very different populations.”

In the last few years, that has meant that the innovations of Patel and his colleagues at Sangath, an NGO in Goa, India, have been focused on scaling up access for people with mental disorders. For one, they’ve focused on “task-shifting” (sometimes called “task-sharing”), which is the practice of training paraprofessionals to offer clinical care for a limited range of health issues.

The effort helps address tremendous global inequity in access to mental healthcare. (As Patel described it in a paper for PLoS Medicine, “One country alone [the U.S.] enjoys more psychiatrists than the world’s most populous countries [India and China] and an entire continent [Africa] put together.”) The innovation expands the number of patients who can access appropriate care, while freeing doctors to manage unusually complex cases.

Sangath has combined task-shifting with “packages of care,” an approach designed to ensure a patient can access diagnosis, psychotherapy and drug therapy from one provider working in a primary care setting. Combined with task-shifting, packages of care permit lower-level workers trained to address a specific mental disorder to conduct outreach and screenings, offer prescriptions and talk therapy, and offer referrals. Together, these innovations have proved highly effective.

The focus of Patel and his colleagues is largely on South Asia, and Patel emphasizes depression particularly. But data suggest that depression tends to increase amid income inequality and armed conflict, and in people experiencing psychological trauma — the conditions rife among current migrants to Europe. As what Patel calls “a humanitarian crisis of Biblical proportions” in the Middle East goes on, the need to scale up mental healthcare access might make task-shifting and packages of care relevant beyond the resource-limited settings where it’s currently in use.

Patel says the biggest block is not knowledge, but resources. “If I had a dollar,” he says, “I would put it in … scaling up what we know works.” He adds that “a lot of attention will need to be focused” on ensuring the Middle East and Europe can address the mental health consequences of the current situation.

For some refugees, leaving home might remove critical barriers to mental healthcare (even as the difficulties of migration make that care necessary). Indeed, Patel says, trying to use science to help people is unlikely to make the situation worse. In some parts of the world, he says, “At the moment, no one is getting the care anyway.”