Escape from Ukraine: Mental health in displaced populations.
Since my days as head of Wellcome’s History of Medicine programme (2001–2012) and now as a member of a the SPI-Lab research team at King’s College London, I have a keen interest in historical perspectives of mental health.
As I write this, the Russian president, Vladimir Putin is escalating his unprovoked attack on his peaceful neighbour Ukraine, thus demonstrating amongst other things, utter contempt and disregard for the health and wellbeing of the Ukrainian people. Whilst western governments impose hard-hitting economic sanctions, people around the world stand in solidarity with Ukraine and wonder where it will all end, and whether the country and its people will ever be the same again.
Not only are the shelling and air strikes causing civilian casualties, but the future is also bleak for those who are ‘lucky’ enough not be in the direct firing line. A significant proportion of the population is on the move, looking for sanctuary in neighbouring countries to the west. This is obviously a common consequence of conflict — mass migration of population to a safe haven; but we know from other significant migrations in history this is not the end of the matter from a population health perspective.
In 1947, the partition of British India for example, led to the creation of two independent nation states: Hindu-majority India and Muslim-majority Pakistan. As a consequence, millions of Muslims left their homes and travelled to either West or East Pakistan (now Bangladesh), whilst Hindus and Sikhs marched in the opposite direction. Unprecedented sectarian violence erupted within these communities that had previously co-existed peacefully for hundreds of years. By 1948, more than fifteen million people had been displaced and over one million were dead as a consequence of the migration.
I cite this example as I was recently reminded of an enlightening conversation I had with Professor Sanjeev Jain at India’s National Institute of Mental Health and Neurosciences (NIMHANS) in Bengaluru back in 2009. I spent a fascinating afternoon in Sanjeev’s office just listening to his stories of the partition and how the mental health of millions of people was affected. He explained that, although the impact was huge and multifactorial, mainstream psychiatry had largely ignored the psychological scars of partition on both the Indian and Pakistani populations. It was this silence that led him to highlight this important but hidden part of medical history in India with his research and resulting edited volume. I am glad to say his keenly anticipated book, “the Psychological Impact of the partition of India” (with Alok Sarin) was finally published in 2018 (Sage Books).
In their book, Jain and Sarin examine potential reasons for the silence surrounding the mental health consequences of partition asking whether, for those with lived-experienced, the mental trauma of the partition was too intense to allow into the consciousness of the nation. Or perhaps it was because those affected were just ‘ordinary’ people who were never given the opportunity to verbalise their feelings and the impact of their poverty, disempowerment or marginalisation. Whatever the reason for this ignoring of the effects on mental health caused by the Partition, it is, according to Jain and Sarin, in stark contrast to the wholly justified consideration given to the psychological impact of the aftermath of the Second World War and the Holocaust.
Research on the psychological consequences of WW II initially, quite-rightly focused on Holocaust survivors, but by the 1990s researchers began to investigate the psychological impact of WW II trauma on civilian populations, specifically looking at the prevalence of post-traumatic stress disorder (PTSD). Impact on the post-war Polish population provides a relevant salutary tale with what may begin to unfold in Ukraine. As we know, Poland suffered huge losses and social upheaval, and as a consequence had PTSD rate of over 30% (in 70–96yr olds all born before 1945). Not only that, because of the socio-political situation, i.e., coming to terms with the communist regime, Polish people faced often insurmountable barriers in coping with their trauma. This repressive environment meant that they were not able to share their war-related trauma experiences in a stable, safe, and supportive community.
We know that pre-migration trauma does predict mental health disorders and PTSD, and there is little we can do about that now given the invasion and bombing is underway in Ukraine but post-migration factors are key to recovery. Unstable living arrangements, lack of economic opportunities in their new home or when they return to their country of origin, and lack of political resolution of the conflict, are all associated with poorer mental health outcomes. Loss of and separation from loved ones as well as the nostalgia for the homeland are often cited as a source of psychological distress that creates an overwhelming sense of sadness.
Today, the United Nations estimates that there are over 65 million people (UN Global Trends Report) worldwide who are currently displaced by conflict or persecution, — a number added to by at least 0.5 million so far during the current situation in Ukraine.
Europe, of course, has recent experience of dealing with a sudden, mass influx of displaced peoples. One only has to look back to 2016 and the arrival of half a million refugees from Syria to realise that we (the West) don’t exactly have a glowing track record in dealing desperate people displaced by war. In the summer of 2016, public opinion and government policies fluctuated wildly and led to a chaotic response whilst European nations wrangled about how many refugees to accept and tried to stop the influx from countries such as Greece and Italy.
Furthermore, we know that Syrian culture (similar to Ukrainian) is family orientated and a major cause of trauma in the Syrian crisis was family separation. Families become separated when they are forced to flee at different times or, as we have seen this week in the news from Ukraine, men stay behind to fight whilst the women and children flee to safety. We will need to provide safe family reunification pathways for split families which may involve several European countries. As European nations come to together and rightly open their borders to any Ukrainians who wish to leave, we in the west need to heed the lessons from history.
We cannot ignore the impact on mental health and therefore we need to ensure we provide supportive mental health services and psychosocial interventions as well as welcoming environments to mitigate against the psychological scars on the Ukrainian nation.
For Ukrainian people’s sake, we have to hope we do much better this time around.
We are deeply saddened by and concerned about the terrible events in Ukraine. Our thoughts and prayers are with the people of Ukraine and we will continue to raise awareness for this frightening humanitarian crisis. It is heartwarming to see the kindness and solidarity shown in these frightening times with campaigns such as the Emergency Appeal from a fellow KCL/IOPPN psychiatrist who will be delivering medical supplies to those in desperate need.