African refugees in Durban: discrimination, food insecurity

and mental health

Prof Jonathan BurnsHead of Department of PsychiatryNelson R Mandela School of MedicineUniversity of KwaZulu-NatalDurban, South Africa

The epidemiology of migration – Humans have been migrating for millions of years

The epidemiology of migration –Human migration during the 20th Century

The epidemiology of migration –20-30 million internally displaced people

Migration is associated with an increased risk for mental disorders

• Anxiety & Depression In the UK, Asian & Afro-Caribbeans (especially women) are 1.5-2.5 times more likely to be diagnosed with anxiety disorder or depression (Bhugra & Jones 2001)

• Post-traumatic stress disorder – high rates of PTSD in refugees from El Salvador, Tibet, Khmer, China, Ethiopia, Kosovo (Fazel et al 2005) – mean prevalence of 9% (highest: 44% Cambodian & 38% Kosovan refugees)

• Suicide & attempted suicide – elevated rates in S. Asian female diaspora globally, especially aged 18-25yrs. Factors: males – socio-economic status; females – cultural transitions & tensions (Bhugra & Jones 2001)

• Substance abuse

Increased prevalence of schizophrenia in migrants

• Afro-Caribbeans in UK and Netherlands have increased rates of schizophrenia (range from 2-16 x local white population).

• Systematic review (Cantor-

Grae & Selten 2005) – 3x risk.

Reasons for increased prevalence of schizophrenia in migrants

1. Higher rates in countries of origin – NO

2. Schizophrenia predisposes to migration – NO

3. Misdiagnosis in ethnic minorities – NO

4. Stress of migration itself – evidence shows that onset of schiz is usually 10-12 yrs post-migration and is increased in 2nd generation.

Reasons for increased prevalence of schizophrenia in migrants

Ethnic density & perceived discrimination:

• Rates are increased where the individual’s ethnic group is significant minority in community

• Perceived racism and discrimination correlates with increased risk for schizophrenia

Boydell et al 2001

Veling et al 2006

Stages of Migration• Pre-migration• Migration• Post-migration

Reasons for migration• Political• Economic• Educational

Migrate singly or en masse

Important pre-migration factors

• Reasons for migrating• Alone or with family/group• Personality of individual• Trauma, persecution• Prepared or sudden• Degree of control over

migration

Important migration factors

• Traumas experienced• Vulnerable groups

(women, children, elderly)• Alone or with family/group• Legal illegal/asylum• Host country response

(eg immigration policies)• Financial means• ‘cultural bereavement’

(loss/grief reaction) – normal response

Vulnerable groups

Host country response/policies

Important post-migration factors

• Aspirations & expectations versus achievement

• Acculturation & adjustment• Cultural identity shifts• Culture shock• Ethnic conflict, xenophobia• Ethnic density, networks,

support• Unemployment, housing• Legal problems, detention

Cultural bereavement- Loss of social structure,

supports, economic worth, language, culture, values, identity, etc

- A normal grief reaction

Culture shock- Transition from eg. Socio-

centric society to an Ego-centric society

Cultural identityContact may lead to:- Assimilation- Rejection- Integration- Deculturation

Cultural congruity- Socio-centric vs ego-

centric societies- Individual personality

(socio- vs ego-centric)- Adjustment varies

Ethnic density

• Size of ethnic group in proportion to total pop in a region

• Increased ED may be protective, supportive

• But increased ED may delay adjustment and increase stress in eg. ego-centric individuals

Refugees, migration and xenophobia

• SA: 2001 census: > 1 million refugees from within Africa (probably higher: ½-1million current from Zimbabwe)• Internal migration/urbanization (mines, etc)• May 2008 – xenophobic attacks (>70 killed, 10s of 1000s displaced and homeless); again in 2015

Durban Migrant Mental Health Study

• Dennis Hurley Centre – FBO• 6 months in early 2014• 335 adult refugees/migrants• Socio-demographics• Pre/Migration/Post factors• Food security• Discrimination• PTSD symptoms (Harvard Trauma Questionnaire)• Anxiety & depression (Hopkins Symptom Checklist-25)• Life Events Checklist

Demographics % %

Male 53

DRC 48

Zimbabwe 34

Burundi 14

Married/partner 57

Mean age (years) 33

Mean years of schooling 11

Occupation: before vs after migration: - unemployed - student - teacher/professional - artisan/labourer - part-time

Before

143123150

After

306112711

Pre-migration/migration factors %

Reason for leaving: - To escape war, violence, danger, arrest - To seek employment, study - To join relatives, friends

70282

Forced to leave suddenly or quickly 70

Traveled to SA: - alone - with family - with friends - with strangers

6119126

Substance use: - alcohol - cannabis

231

Post-migration factors %

Currently living alone 7

Mean number of people living in home 5

No income or less than $100/month 29

Last 12 months, not enough food to eat: - often - sometimes

2338

Have you felt discriminated against? 71

Where? - home country only - both home country and in SA - in SA only

72370

Family separation since being in SA 33

No social support 23

Trauma exposures

Trauma % Trauma %

Lost a child 17 Sexual assault 5

Natural disaster 28 Combat/exposure to war

57

Fire/explosion 16 Captivity or hostage 12

Transport accident 39 Life-threatening illness or injury

28

Physical assault 67 Sudden death of loved one

68

Assault with weapon 46 Torture 13

Mental health outcomes

Outcome %

HSC anxiety score ≥ 16 50.3

HSC depression score ≥ 24 53.9

HTQ PTSD score ≥ 60 25.9

Anxiety Depression PTSD

Nationality - Zimbabwe - DRC - Burundi

17.916.815.3

29.726.623.4

54.249.343.6

Household income ($/m) <100 100-250 250-500 500-1000 >1000

19.417.616.414.314.2

31.128.825.722.222.2

58.752.446.741.539.8

Last 12 months, not enough food-Yes-No

18.414.8

29.922.8

55.141.7

Anxiety Depression PTSD

Forced to leave family behind - Yes - No

18.216.4

29.925.9

56.047.1

Discrimination in SA - Yes - No

18.716.1

30.025.5

55.746.6

Lost a child - Yes - No

19.316.6

30.526.6

55.249.0

Natural disaster - Yes - No

16.017.4

26.527.4

48.650.6

Fire/explosion - Yes - No

19.216.5

30.126.4

57.248.2

Anxiety Depression PTSD

Sexual assault - Yes - No

20.616.8

33.826.8

59.149.5

Combat/exposure to war - Yes - No

16.317.8

25.429.3

46.354.3

Captivity/hostage - Yes - No

18.516.8

30.826.6

57.848.8

Life-threatening illness - Yes - No

19.216.1

30.925.5

56.647.1

Torture - Yes - No

20.916.4

34.526.0

67.447.3

Food security and anxiety, depression

AnxietyOR

DepressionOR

Food insecurity 5.4 7.2

Female ns 1.9

Divorced 3.5 1.8

Forced to leave ns 2.1

No social support ns 1.5

Post-migration adaptation

• Recent arrival in SA - depression(OR 3.1)

- PTSD (OR 4.7)• Older age on arrival - depression (OR 5.6)

- anxiety (OR 5.3)• Family separation

since arrival - depression (OR 2.4)

- PTSD (OR 2.3)• Discrimination in SA - depression(OR 2.5)

- anxiety (OR 1.9)

- PTSD (OR 2.4)• Divorced - PTSD (OR 3.1)• Low income - PTSD (OR 2.2)

Conclusions

• African refugees in SA are a vulnerable group• High levels of trauma exposure pre-migration• In SA they encounter major problems of poverty and

food insecurity, hostility, discrimination/xenophobia, and violence

• Half have anxiety & depression, and a quarter PTSD

Major risk factors for mental health problems:

Pre-migration factors:

- previous traumatic experiences

- being forced to leave

Post-migration factors:

- food insecurity

- low income

- discrimination in host country

- lack of social support

Take home messages

1. Trauma leads not only to PTSD, but also to other mental disorders

1. While pre-migration exposure to trauma is an important cause, post-migratory challenges and difficulties are also potent drivers of mental health problems in this vulnerable population

Acknowledgements

Andrew Tomita

Charlotte Labys

Varsha Maharaj

Lindokuhle Thela

Mpho Mhlongo

Dennis Hurley Centre

South African Medical Research Council

burns@ukzn.ac.za