A crisis within the crisis: The mental health situation of refugees in the world during the 2019 coronavirus (2019-nCoV) outbreak.

BACKGROUND: 68.5 million people around the world have been forced to leave their houses. Refugees have mainly to face their adaption in a host country, which involves bureaucracy, different culture, poverty, and racism. The already fragile situation of refugees becomes worrying and challenged in the face of the new coronavirus (COVID-19) epidemic. Therefore, we aimed to describe the factors that can worsen the mental health of refugees.
METHOD: The studies were identified in well-known international journals found in three electronic databases: PubMed, Scopus, and Embase. The data were cross-checked with information from the main international newspapers.
RESULTS: According to the literature, the difficulties faced by refugees with the COVID-19 pandemic are potentiated by the pandemic state. There are several risk factors common to coronavirus and psychiatric illnesses as overcrowding, disruption of sewage disposal, poor standards of hygiene, poor nutrition, negligible sanitation, lack of access to shelter, health care, public services, and safety. These associated with fear and uncertainty create a closed ground for psychological sickness and COVID-19 infection.
CONCLUSIONS: There should be not only a social mobilization to contain the virus, but also a collective effort on behalf of the most vulnerable populations.

68.5 million people around the world have been forced to leave their houses (Moreira et al., 2018) because of war, violence, or oppression. Nearly 21.3 million of these are refugees. In addition, 40.8 million are internally displaced. Globally, 6% of the world's displaced people are hosted in Europe and 12% in the Americas (Hvas; Wejse, 2017).

Immigration involves several stressful events for youth and their families during the process of immigration and even after the settlement. Refugees have mainly to face their adaption in a host country, which involves bureaucracy, different culture, poverty, and racism (Tryantafyllou et al., 2018). Moreover, settling in crowded shelters without clean water and inaccessibility to health care services makes people more vulnerable to get an infection (Shokri; Sabzevari; Hashemi, 2020). Hence, the already fragile situation of refugees becomes worrying and challenged in the face of the new coronavirus (COVID-19) pandemic that occurred in Wuhan, China, in December of 2019. This has been responsible, until 29 March 2020, for a total of 575,444 cases confirmed in the 202 countries including 26,654 deaths (WHO, 2020). Therefore, we aimed to describe the factors that can worsen the mental health of refugees.

The first difficulty faced by refugees is language and access to information. According to data from the United Nations High Commissioner for Refugees (UNHCR), digital platforms are useful for sharing quality information and keeping contact with local representatives and groups of refugees (UNHCR, 2020a). The great challenge is to screen information on prevention and health promotion about COVID-19 and to adapt them to the routines of thousands of families in refugee camps, while dealing with situations bordering on their physical and psychological health.

The second difficulty refers to the sociocultural differences between refugees and countries that receive them, as well as discrepancies in health care practices that do not align with their cultural or religious beliefs (Phillbrick et al., 2017).

The third difficulty is the overcrowding of fields and intimate human contact, due to the precarious housing situations. In Greece, for instance, there were 38,000 refugees living on 6200 m2 in Moria camps (AFP, 2020). A refugee camp in Bangladesh is so cramped that its population density is nearly four times higher than that of New York City, making social distancing impossible (Beech; Hubard, 2020). This situation, as that of several other camps, is worrying, as the most effective methods for controlling COVID-19 are identifying the communicants and quarantining them; protecting health professionals with personal protective equipment; and identifying symptomatic patients, performing tests, giving results quickly and isolating them (Silva, 2020).

The fourth difficulty is the high numbers of refugees that can represent overload and major challenges to health care systems and local refugee voluntary agencies in host societies, especially mental health care (Morina; Hoppen; Priebe, 2020). Clinics in a refugee camp in Kenya have been struggling with only eight doctors for nearly 200,000 people (Beech; Hubard, 2020). Phillbrick et al. (2017) state that voluntary agencies have been given very limited government financial assistance to aid refugees in obtaining food, housing (including furniture), clothing, local language education, employment counseling, education, and medical care in the United States. The UNHCR has been accepting funds to deal with the COVID-19 pandemic throughout the world. It seeks $255 million to provide support to displaced people and migrants in the fight against the disease that affects almost the whole world. Their intention is to provide laboratory equipment for tests and medical supplies for the treatment of patients affected by COVID-19; to disseminate information campaigns; to send supplies to needy regions and to move medical work teams across territories (UNHCR, 2020b).

The fifth difficulty, paradoxically, is the shutdown of government services and a considerable decrease in volunteers due to quarantine. These situations are quite unsettling and can be exemplified by camps across Germany, France, Greece, Brazil (O Globo, 2020), Africa, the Middle East and Asia, where there are traumatized and undernourished people with limited access to health care resources and basic sanitation (Beech; Hubard, 2020).

For these various reasons, this population has a high risk of developing psychiatric disorders, which is worsened in the face of the COVID-19 pandemic. Overcrowding, disruption of sewage disposal, poor standards of hygiene, poor nutrition, negligible sanitation (Shokri; Sabzevari; Hashemi, 2020), lack of access to shelter, health care, public services and safety are risk factor for COVID-19 and mental illness that when associated with fear and uncertainty creat a favorable situation for the psychological and biological illness of these communities (Bulik; Colucci, 2019). A Greek study compared the number of psychiatric diagnoses of refugees in Greece with natives, showing a rate almost four times higher (Tryantafyllou et al., 2018). Systematic reviews show that prevalence estimates of mental health disorders for this population vary widely from 20 to 80%: 4 to 40% for anxiety, 5 to 44% for depression, 9 to 36% for posttraumatic stress disorder (Slewa-Younan et al., 2015).

Therefore, during the pandemic of COVID-19, there should be not only a social mobilization to contain the virus, but also a collective effort on behalf of the most vulnerable populations – biologically and psychologically with holistic support for both the humanitarian issues and the containment of the pandemic.

Authors’ contributions

MLRN, JGJ, JPS, CKTL, MMM designed the review, developed the inclusion criteria, screened titles and abstracts, appraised the quality of included papers, and drafted the manuscript.

MLRN, JGJ, WRP, CKTL, JPS reviewed the study protocol and inclusion criteria and provided substantial input to the manuscript.

MLRN, JGJ, JPS, MMM, WRP reviewed the study protocol. MMM read and screened articles for inclusion. All authors critically reviewed drafts and approved the final manuscript.

Funding

The researchs groups: Statistical Modeling, Simulation and Risk Optimization, Department of Engineer; Scientific Writing Lab, Medicine School – Universidade Federal of Cariri (UFCA) and the Suicidology Research Group from Universidade Federal do Ceará (UFC) and Brazilian National Council for Scientific and Technological Development (CNPq) – institution linked to the Brazilian Department of Science, Technology and Innovation to encourage research in Brazil.

Declaration of Competing Interest

The authors declare that they have no competing interests.