The Mental Health of Refugees during a Pandemic: The Impact of COVID-19 on Resettled Bhutanese Refugees

Asian Bioethics Review https://doi.org/10.1007/s41649-021-00183-1 ORIGINAL PAPER The Mental Health of Refugees during a Pandemic: The Impact of COVID‑19 on Resettled Bhutanese Refugees Tanner McGuire1 · Daniel Yozwiak1 · Julie M. Aultman1 Received: 2 February 2021 / Revised: 22 July 2021 / Accepted: 27 July 2021 © National University of Singapore and Springer Nature Singapore Pte Ltd. 2021 Abstract This paper is the first of two in a series. In this paper, we identify mental health needs and challenges in the age of COVID-19 among Nepali-speaking, Bhutanese resettled refugees in the USA. We argue for a public health justice framework that looks critically at social determinants impacting mental health (SDIMH) barriers, which negatively impact our Bhutanese population, and serves as a theoretical foundation toward public policy and law that will inform healthcare decisions and fair treatment of resettled refugees at the clinical bedside and in the community. We first describe our Bhutanese refugee population and the critical mental health issues that, for many, originated during political persecution and violent ethnic cleansing initiatives, or while living in refugee camps prior to resettlement to the USA. We present a social justice framework emerging from an extensive literature review and incorporating core social determinants specific to mental health in the age of COVID-19, which are guided by the social determinants of economic stability; neighborhoods and physical environment; education; nutrition and exercise; community and social context; healthcare system; and legal system. We illustrate specific SDIMH of our resettled Bhutanese refugees during the pandemic, followed by a second paper that details recommendations for applying the SDIMH in a collective effort to address specific barriers to mental healthcare and support. Keywords Justice · Social determinants · Refugee · Mental health · Pandemic · COVID-19 Increased mental health and suicide risks among resettled refugees in the USA pose extensive legal, ethical, and clinical challenges for healthcare professionals, legal * Julie M. Aultman 1 Northeast Ohio Medical University, Rootstown, OH, USA 13 Vol.:(0123456789) Asian Bioethics Review advisors, community leaders, and advocates. These challenges stem from sociocultural differences, legal obstacles, and medical histories that have been complicated by refugee encampment and the resettlement process.1 The mental health of Nepalispeaking refugees especially has been impacted by persecution and displacement from Bhutan, challenging living conditions in the Nepali refugee camps, and interdependent social determinants of health during resettlement. Additionally, during the COVID-19 pandemic, refugees in the USA are at higher risk of getting COVID19 because of living or working conditions, and other social determinants (Centers for Disease Control and Prevention, n.d.). The pandemic has only exacerbated specific social determinants impacting mental health (SDIMH) among the Nepalispeaking refugee community. Rates of mental illness among the Nepali-speaking community surveyed by the Centers for Disease Control (CDC) show rates of depression and anxiety at 21%, and a rate of suicide nearly two times that of the general US population (Ao et al. 2016). The Ohio Mental Health and Addiction Services found mental illness rates among the Nepali-speaking community in Ohio, the third largest receiver of refugees in the USA,2 much higher than the national average with 30% suffering from symptoms of anxiety and 26% from depression (Adhikari et al. 2015). Additionally, 21% in Ohio reported their family members had completed suicide, compared to only 5% in the national CDC study (Adhikari et al. 2015). Though these rates are high, they are likely underreported due to stigma and linguistic barriers (Adhkari et al. 2015; Ao et al. 2016). Thus, depending on the location of resettled Bhutanese refugees, rates of mental health issues, including suicidality, can be three times as high as the rest of the population. These exceedingly high rates call for a careful examination by resettlement communities and healthcare providers of contributing factors and potential solutions that yield improved health outcomes and social justice. Our discussion of these issues will take place over the course of two separate articles. In this first article, we explore the historical and cultural background of the Bhutanese refugee community and the social determinants which impact their mental health. In the second article, we examine the current treatments and 1 We will refer to our focus population throughout this manuscript as Bhutanese refugees or resettled Bhutanese refugees. We recognize that many of our refugees are Nepali-speaking and/or Nepali-born; others speak several languages and were born in Bhutan. Some have been born in refugee camps or in their resettled communities and will refer to themselves as Nepalese Bhutanese Americans, for example. We recognize that a person’s identity is tied to their family, place of birth, place of origin (e.g., refugee camp), and/or their citizenship. 2 In addition to being the location of this research team, Ohio is a top refugee-receiving state and the locale where a vast number of Bhutanese refugees have resettled in recent years. In 2017, Ohio received over 2000 refugees, the majority of whom were Bhutanese (Galvin 2018), followed by the resettlement of 1408 refugees in 2018 (National Immigration Forum 2019). And last year, during fiscal year 2019, Ohio welcomed another 1400 refugees (Krogstad 2019). To put these numbers into perspective, we can compare them to global statistics published by the United Nations High Commissioner for Refugees (UNHCR, n.d.b). In 2017, Ohio resettled 2085 refugees—more than Ireland (308), Spain (1373), Italy (1392), and New Zealand (1309). Canada resettled about 4000 refugees the same year. In 2018, France resettled almost 5000 refugees, Germany resettled 4277, and Japan resettled 37. Even when placed on a global scale, Ohio’s resettled refugee population is significant in size and can provide great insight into the struggles faced by refugee communities nationwide. 13 Asian Bioethics Review alternative approaches to healing mental illness and discuss the many ways in which our healthcare systems, governments, local communities, and leaders can better support the Bhutanese refugee community. The COVID-19 pandemic has posed significant barriers to provide care and social support; increased issues of isolation and addictive behaviors, heightened anxiety, fear, and experiences of discrimination, among other barriers, have impaired progress toward social justice. As Gostin and Powers (2006, 1054) write, “public health that is based on social justice can address health determinants and plan for health emergencies with ‘an eye on the needs of the most vulnerable’”. In light of the recent pandemic, it is essential to (...truncated)