How Stigmas Impact Refugee and Migrant Health

Waheed Arian spent the first five years of his life hiding in cellars from rockets and bombs.

Arian, an emergency doctor with the UK's National Health Service, was born in Kabul in the 1980s in the midst of the Soviet-Afghan war.

Life wasn't easy: His family did not have enough food or clothes, and he and his siblings suffered from whooping cough.

When Afghanistan became too dangerous for the family, they traveled to Pakistan. With borders closed, the only way to get there was via a dangerous mountain route, which they traversed on the backs of donkeys and horses.

On the journey, the family came under attack three times, Arian said. They survived and eventually made it to a Pakistani refugee camp, where they, along with many others, lived in tents. Temperatures soared to up to 45 degrees Celsius (113 Fahrenheit).

"These are the sort of conditions that are ripe for several diseases, such as malaria and tuberculosis. Many of my family members, including myself, got malaria. We survived that, and soon I contracted tuberculosis, which nearly killed me," Arian told a World Health Organization press conference on Wednesday.

Tight quarters in refugee camps can provide conditions that stimulate the spread of tuberculosis. In Jordan, 29.3% of TB cases among Syrian refugees are in those who live in camps, according to the WHO report. That's despite the fact that only around 17% of the country's Syrian refugees reside in camps

Still happening today

A new WHO report outlining the many aspects that impact refugee and migrant health shows that stories like Arian's are still happening today. Although his experience with migration occurred in the 1980s, little has changed over the past 40 years.

"The conditions that we see in refugee camps now in various parts of the world, they're not too dissimilar to the conditions that I experienced firsthand. Although we were safe from bombs, we were not physically safe, we were not socially safe, and we were not mentally safe," said Arian.

Eventually, at the age of 15, Arian was sent alone to the United Kingdom. There, he suffered from post-traumatic stress disorder, or PTSD. However, he was able to get through it and eventually went to university, where he studied to become a doctor.

High rates of depressive disorders

Arian's story highlights the many aspects of health that are affected when a person is forced to migrate. Although his success is unique, his childhood is not unlike those of millions of people growing up in conflict regions across the world.

The WHO report illustrates how the various stages of the migratory journey can impact a person's well-being: From the route to safety, to the isolating temporary homes people are forced to live in when they reach safer countries, to the discrimination and bureaucratic struggle they face when dealing with health care systems in their new homes.

Arian's PTSD diagnosis illustrates that the physical harm to safety — attacks, extreme heat, threat of various diseases in tight living quarters — is almost always accompanied by mental anguish, which can remain for life, even once a person is no longer living under physical threat.

In Europe, the prevalence of depressive disorders among refugees and migrants is 32%, significantly higher than the prevalence among the host population at 4%.

The 322-page report, and Arian's story, show there are hundreds of ways refugee and migrant health is impacted before, during and after the migratory process.

Because we cannot explain all of those reasons in this article, we are going to focus on how stigmas — both self-imposed and within the health care system itself — can exacerbate negative health outcomes.

Overcrowded and often unsanitary life in some refugee camps can be conducive to a host of health problems

Trouble on the route

The challenges faced by people during migration can vary depending on the scenario. One of the biggest problems they face is sexual and physical assault. In situations that involve people smuggling, women often fall victim to sexual assault and exploitation.

But women aren't the only victims of sexual abuse, a fact that is often overlooked and can have a damaging impact on male survivors. For example, in a clinic providing medical care to asylum-seekers in a country in the WHO European region, 28% of sexual assault survivors were men, the report said.

Many said their attack occurred along migration routes, rather than in their country of origin.

Along with trauma from the attack, these men may experience shame — both a kind of self-imposed shame prohibiting them from reporting abuse, as well as stigma in health care facilities.

When they do decide to report, male sexual abuse survivors are often faced with negative attitudes from health care providers and staff, such as disbelief and lack of empathy, and find themselves subjected to humiliating comments from service providers who hold xenophobic and homophobic stereotypes about male-on-male sexual violence, the report said.

The anticipation of this disbelief and lack of empathy may help explain why damaging stigmas like "men can't be raped" continue to exist — and men don't report.

The report mentioned a study in one country of refugee survivors of sexual violence and torture, including rape, which found that none of the men sought treatment or officially reported their injuries.

Precarious migration routes, like the journey across the Mediterranean Sea to Europe, can cause severe mental stress

Stigma remains pervasive beyond the route

Gender-based stigmas can also impact the mental health of male migrants in other aspects of their lives. For example, the report mentioned something called "depleted masculinity" — a state that occurs when men feel they cannot live up to expectations or fulfill their duties.

Refugee and migrant men reported feeling pressure to fulfill masculine social roles, the report said, like sending money back home and supporting their families.

When this wasn't possible due to the many factors that make employment difficult for migrant and refugee men — from lack of education to lack of language abilities to discrimination — men experienced high levels of stress and feelings of emasculation.

The report said that in the case of male migrants from Bangladesh and Pakistan working in Greece, these feelings drove men to rework their masculine status into self-exploitative contests like fruit-picking competitions that served the employers' interests while undermining worker solidarity.

This gender-related stress is often experienced on top of trauma and PTSD associated with the experiences that caused them to migrate.

Discrimination in clinics

Once they have made it to places of safety, refugees and migrants can still experience barriers to health care.

The negative experiences male sexual assault survivors faced in clinics aren't the only example of barriers imposed by health care systems. Migrants and refugees around the world reported difficulties understanding health care systems and access to benefits and insurance coverage.

This can be due to financial and language barriers and a lack of empathy from health care providers, which can leave people feeling lost and resigned.

This hopelessness was illustrated in a Danish study quoted by the report, which showed that unfamiliarity with the health system, combined with interpersonal miscommunication and perceived cultural insensitivity among health professionals, reduced refugee and migrants' desire to seek medical care.

Access to maternal health services among pregnant refugees and migrants is often difficult

Edited by: Louisa Wright