COVID 19 pandemic: Mental health challenges of internal migrant workers of India.

COVID- 19, a biomedical disease has serious physical and tremendous mental health implications as the rapidly spreading pandemic. One of the most vulnerable, but neglected, an occupational community of internal migrant workers is prone for development of psychological ill-effects due to double whammy impact of COVID-19 crisis and concomitant adverse occupational scenario. Permutations and combinations of the factors viz susceptibility for new viral infections, potential to act as vectors of transmission of infection, high prevalence of pre-existing physical health morbidities such as occupational pneumoconiosis, tuberculosis, HIV infections, pre-existing psychological morbidities, adverse psychosocial factors like absence of family support and caretaker during the crisis, their limitations to follow the rules and regulations of personal safety during the COVID 19 crisis, social exclusion, and inability to timely access the psychiatric services; all give rise to the peri-traumatic psychological distress to internal migrant workers. Superadded, is the blow of financial constraints due to loss of work, absence or suspension of occupational safety and health-related basic laws with associated occupational hazards, which make this occupational group highly vulnerable for the development of psychological illnesses. We attempt to draw the attention of mental health professionals, general medical practitioners and occupational health policymakers to the various, interrelated and interdependent predisposing and causative factors for the development of psychological ill-effects amongst internal migrant workers with the interventions needed to address it, from an occupational health perspective angle.

Introduction

COVID 19 pandemic, as the rapidly spreading disease, has given rise to a series of negative cognitive responses and emotions in the population at risk. As a result, in addition to the adverse effects on physical health, the COVID-19 pandemic has the potential to cause chronic psychological manifestations like depression, anxiety, panic disorder, and psychosomatic manifestations (Qiu et al., 2020; Tandon, 2020).

Asian countries like India, are currently facing the issue of the exponential growth of spread of transmission of SARS-CoV-2 in overcrowded residences of internal migrants in slum areas of urban cities like Dharavi in Mumbai, underprivileged localities of metro cities like Delhi Also latest live example is Singapore, that reported a sudden resurgence of cases of COVID 19 due to rapid growth of transmission of infections in its migrant worker dormitories, which happened after the initial success in the epidemic containment. Active viral clusters of infections can rapidly spread in the low-wage migrant workers if the issue remains unaddressed in COVID 19 containment policy.

During the lockdown period of India, nationwide sudden bans on travel, lack of work led to no financial means to take care of daily food expenses and quarantine rules, all have resulted in high levels of anxiety, which in turn induced socially irresponsible behaviour and panic attacks among internal migrant workers. Recent flee of stranded internal migrant labourers to railway stations and bus stations, making desperate attempts to go back to their home states ignoring lockdown rules is an example of this. This invariably results in the vicious cycle of susceptibility to infection, quarantine, stress, and violation of preventive measures. Anxiety levels are indeed building in these migrant workers, forcing many of them to travel several thousands of kilometers on foot to reach their native places without any provision of food or shelter in the transit.

According to the psychosocial issues among migrants during COVID-19 listed by the , internal migrant workers are suffering from high degrees of anxieties and fears due to various concerns in COVID pandemic, and are in need of psycho-social support (G.O.I., 2020). The continuous reverse migration of millions of migrant workers to their native villages can prove to be detrimental for the mental health and rural India may be particularly susceptible to suicide in near future due to the heavy economic load of jobless migrant workers (Nelson, 2020). Reports of the migrant workers having a serious nervous breakdown and depressive psychotic disorders have started appearing in the print media (Shastri, 2020).

As an occupational health researcher, this is an attempt to raise an alarm by highlighting the unique vulnerability of Asian internal migrant workers for the development of adverse effects on the psyche along with the factors responsible for psychological ill-effects with added occupational health perspective angle.

Internal migrant workers: A vulnerable population

According to an official employment estimation, Indian industries, had about 100 million internal migrant workers, having a sizeable impact on the economics of India. (Deshingkar and Akter, 2009) Internal migrant workers comprise workers, migrated as an individual or in groups, mainly on a temporary or seasonal basis in search of the work to urban areas of other state or geographical regions of India. Rural to urban migrant workers mostly engage in temporary, unskilled work, characterized by low wages, job insecurity and economic vulnerability, which are peculiar characteristics of informal work environments (Zeitlyn et al., 2014) They are predisposed to experience adverse psychological consequences of multiple stresses, generated through interactions of various factors, not limited to chronic poverty, malnutrition, cultural bereavement, loss of religious practices and social protection systems, malalignment with a new culture, coping with language difficulties, changes in identity, substance abuse and poor access to healthcare in addition to the poor living conditions and financial constraints.

In the Indian context, on the backdrop of COVID 19 pandemic, factors that might affect the predisposition of the internal migrant workers for adverse mental health manifestations, are worth considering here

Susceptibility for new communicable diseases

Internal migrant workers are practically highly susceptible to new infections due to interdependent predisposing factors, related to socioeconomic status, occupational hazards, chronic malnutrition, unhygienic living conditions prevailing in their urban accommodations, lack of proper sanitation and pre-existing respiratory infections. Migrant workers can act, as victims of infection and vectors of transmission, spreading the infection to newer areas on reverse migrations.

Pre-existing occupational morbidities as a risk factor

Higher prevalence of occupational pneumoconiosis such as silicosis (Yao et al., 2019), Tuberculosis, (Iravatham et al., 2019) Hypertension, and other predisposing communicable diseases like AIDS. (Deb et al., 2009), when compared with the native population, make migrant workers more susceptible for contracting communicable viral diseases.

Absence of family support and caretaker during crisis

As most of the male migrant workers are not residing with their family members, their loneliness itself makes them fall prey for mental issues like depression (Zhou et al., 2020). Loss of loved ones in the pandemic, and feeling of helplessness to attend the health needs of the family members, staying away at villages might also aggravate the stress.

Proneness to develop common mental disorders

Lonely migrant workers can more likely get affected by the negative emotional responses, secondary to the COVID-19 pandemic, because of pre-existing higher susceptibility to mental stress compared with the non-migrant, background population.

Limitations to follow the rules and regulations of personal Safety

Resource and space limitations render them incapable of following COVID19 containment rules of quarantine, social distancing, hand hygiene.

Pre-existing mental health issues

Even in pre-COVID19 era, the prevalence of mental health problems was high among migrant workers as compared to non-migrants (Virupaksha et al., 2014; Firdaus, 2017). Rural-to-urban migrants are having inferior mental health status than both residents in the destination communities and their rural counterparts in the emigrating communities. This suggests a deteriorative effect of migratory experience on mental health status (Li et al., 2009). Also there is a predisposition for serious manifestations of mental health issues among those, who are prior sufferers of psychiatric conditions, more likely by precipitating the pre-existing or latent illness during sudden outbreaks (Ho et al., 2020; Zhong et al., 2013).

Social exclusion

Social exclusion is adversely associated with mental health of migrants (Li and Rose, 2017). Internal migrant workers suffer from a high prevalence of anxiety, psychotic, and post-traumatic disorders due to socio-environmental adversities, such as loss of social status, discrimination (Mucci et al., 2019). In addition to the problems created by the pandemic, public health strategies such as mandatory isolation or quarantine in the Government’s temporary shelters on return to their original places and social distancing, increase the feeling of loneliness causing mental issues even may lead to suicide (Nelson, 2020).

Peri-traumatic psychological distress during the pandemic

The highest incidence of peritraumatic psychological distress, particularly among migrant workers across all occupations was documented by a large-scale survey during the COVID-19 epidemic in China (Qiu et al., 2020). Anxiety, depression in about 28 % and self-reported mental stress in 8% are reported as the prevalent psychological reactions along with sub -syndromic mental health consequences of the COVID-19 epidemic (Rajkumar, 2020).

Barriers to assess the psychiatric consultation

The current countrywide lockdowns with restrictions on the public transportation systems might inevitably become the social impediments to access psychiatric consultations

Although online mental health services are made available, only a fraction of the migrant workers, who have access to internet services and smart phones, may be benefitted from such service provisions.

Economic constraints due to loss of work

Predominantly working in informal occupations are bound to suffer from job losses due to restricted or negative industrial growth. Recently, textile industries of Surat city, which mainly employ migrant workers have announced stoppage of production activities anticipating the loss of export orders and decreased internal demands Repercussions can be the sudden unemployment for lakhs of migrant workers with minimal hopes to get new jobs in near future

Absence of effective laws for unorganized sector workers

The unorganized sector migrant workers are not covered by any employers’ social security or insurance scheme and as such regarded as a neglected workforce, with only a few, insufficient legislations, like ‘The Building and Other Construction Workers Act, 1996’ to prevent their exploitation.

Even though an occupational disease is distinctly defined as a disease contracted by an employee, that has arisen out of and during the course of employment, at present the debate is going on whether the infection of COVID 19 acquired during work should be considered as an occupational disease or not, making it imperative for the workers to endure the COVID 19 related medical expenses

Acute and chronic adverse effects of the SARS-CoV2 on the nervous system and mental health

SARS-CoV-2 alike other corona viruses responsible for the past epidemics in 2003 and 2012, may be biologically neurotropic and clinically neurotoxic, causing mental health and neurological disorders (Holmes et al., 2020).

Adverse occupational health scenario during lockdown and post lockdown period

Granting partial relaxations in the lockdown, the Government has allowed restarting the factories with a reduced number of workers and some state governments have also granted exemptions from legal provisions, which were originally aimed at protecting laborers in factories, industries, and other establishments. (Editorial, The Hindu,8th May 2020) The acute shortage of workers in urban areas as a result of reverse migration, along with relaxations in basic occupational and industrial health-related laws, has forced the available workers to work for 12 h rather than usual 8 h shift mainly to boost the production. However, it is contradictory to the Factories Act, 1948. The longer working hours in the absence of protective welfare legal provisions would also mean a reduction in rest hours and consequential increase in the psychological stress and may lead to occupational mental illnesses (Rivera et al., 2020; Wong et al., 2019). Considering these lacunae, effective laws, protecting the welfare and financial interests of the unorganized sector workers during disasters and health crises, is the need of the hour.

Hence the public health policymakers, while framing COVID-19 epidemic policy need to pay adequate attention to the psychosocial issues of the internal migrant laborer. Ignorance of the discriminatory impact of the pandemic on the internal migrant workers will not only hamper our efforts to prevent future spread of COVID-19, but can also magnify pre-existing mental health disparities.

Building a holistic intervention system including screening for psychological stress, and targeted intervention is essential to reduce psychological distress and prevent future mental health consequences. Along with mental health professionals, factory medical officers, general medical practitioners, trained community health workers, should also be integrated with the public mental health services to tackle the upsurge of mental illnesses in the internal migrant workers.

Conclusion

Internal migrant worker is a vulnerable community for the development of severe, acute and chronic, adverse mental health consequences due to COVID 19 pandemic, through various multidimensional factors, many acting concurrently to cause physical, mental, and socio-economical adversities. Besides, the restrictive measures adopted during lockdown and containment COVID 19-policy, associated down gradation of the legislations and laws of occupational safety and health in India, has the potential to aggravate and precipitate the adverse effects on the psyche of internal migrant workers Considering the detrimental occupational angle, which enhances the vulnerability, the mental health community should prepare themselves for handling the challenge of an upsurge in the psychological illnesses among this occupational community Mental health is a critical aspect that needs to be addressed, making it imperative to initiate steps against the psychological ill effects due to pandemic through generating awareness and psychological preparedness among the internal migrants

Financial disclosure

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

None.