Providing psychosocial assessment and support for migrants: A critical urge

 

© UNODC

The number of people moving between and within countries is growing rapidly. However, despite the fact that communication and transportation systems are becoming more efficient and making migration easier, the fact remains that migration is always stressful and at times traumatic. The situation is being made worse as a result of the politicization of migration and the tendency to present migrants as the root of current financial and inter-cultural problems.

To date most of the focus on migration and migrants has centered around issues such as employment, housing and remittances. Psychosocial adaptation issues have been seen as far less important. At ICMHD, the psychosocial aspects of migration are considered a high priority. Studies have repeatedly shown that the risk of physical morbidity and mortality is higher among migrants than indigenous populations and migrants are far more likely to be subject to chronic anxiety, depression, psychosomatic complaints, posttraumatic stress disorders and other psychoses.

Migrants are exposed to stressors throughout the different stages of migration.  Prior to migration they often come from harsh living conditions in their country of origin and have experienced marginalization, social disruption and physical violence.  During the migration process, which can take months and even years, they are often exposed to even greater stressors such as poverty, living in political limbo, job insecurity, extreme exploitation in the work situation and violence.  Even after migration, they often encounter additional difficulties such as cultural conflict, occupational insecurity, social marginalization and in the case of some countries, political hostility in the countries they settle in.  Barriers such as language, religion, culture differences serve to accentuate these problems, amplifying the negative experience even more.  Studies also reveal that migrants have less easy access to local health care systems due to their lack of knowledge, problems of insurance, legal status and poor education.  Coping with these problems is never easy and many migrants turn to behaviors that while helping them deal with these immediate problems, nevertheless present serious threats to their overall health and well-being.  This is not to say that social support mechanisms are not available to migrants, for indeed these can be found in many forms. Evangelical church movements, for example, are increasingly evident in migrant communities everywhere and are rapidly playing the role that formal health care systems and mental health specialists might otherwise have played.  One of the difficulties that mental health specialists have encountered in the past has being their lack of training in cultural competency.  Their lack of familiarity with different cultures and customs has often led to major problems in terms of poor diagnosis and inappropriate treatment of migrants.  In a world that is increasingly heterogeneous in terms of culture, social background, language and beliefs the health sector must adjust its policies and practices and do everything possible to look at the arrival and eventual integration of migrants in a far more rational and long term vision manner.

At ICMHD, we believe that more research is called for this area and that the findings of good research need to become the basis for national policies and programs in the area of psychosocial welfare and integration of migrants.

Manuel Carballo and Madiha Nasir

Rape in the DRC is not a new problem but it is a serious one

RAPE IN THE DRC IS NOT A NEW PROBLEM BUT IT IS A SERIOUS ONE

Manuel Carballo, Jennifer Drummond and Daniel Williams

Global attention has suddenly been focused on the gang-rape of 200 women, girls, and possibly boys in the Democratic Republic of Congo (DRC).  What action will come of these reports and the subsequent outrage remains to be seen.  Rape is not new to the DRC, nor, indeed, to any conflict situation.  In many cases mass rape in conflict is planned and organized in an attempt to undermine civil society and social cohesion, and this seems to have certainly been the case in recent wars.  The attention of the international community was especially drawn by the media to the use of rape as a tool of war during the conflict in Bosnia.  Some 40,000 women and girls (and men and boys) were kept in prison camps and other locations, repeatedly violated and often impregnated.  But Bosnia was by no means unique, and as more attention was focused on the problem it became clear that few wars have been free of mass rape.

(WOMEN'S UN REPORT NETWORK, 2008)

The situation in the DRC, however, remains somewhat distinctive by virtue of the duration of the conflict and the large number of women who continue to be raped on a daily basis by forces from inside and outside the country, including militias, rebels, and other armed groups.  A recent report in the Journal of the American Medical Association found that almost 40% of women and more than 23% of men reached in a survey in the eastern provinces of the DRC had been sexually assaulted since the start of the war.  And according to the UNFPA, there were 17,500 reported incidences of sexual violence in 2009.  Many of these rapes in the DRC have been followed by highly damaging mutilations that have left victims with massive and very difficult-to-treat physical injuries in addition to profound social and psychological scarring.

Over the coming weeks, there will no doubt be a surge of investigations into recent events and fingers will be pointed.  Hopefully there will also be a consolidated and much more rigorous response to what is now a well documented and long-standing problem.  In 2008, the International Centre for Migration, Health, and Development (ICMHD) was asked by MONUC and the UN to assess the situation and propose a course of action.  The resultant Accelerated Plan for Reducing and Mitigating Sexual and Gender-Based Violence in the DRC identified seven priority areas for action that we believe would provide a solid foundation for strengthening the fight against rape and other forms of sexual gender based violence.

(kinshasa.usembassy.gov)

The ICMHD Accelerated Plan concluded that one of the problems was the marked lack of coordination among UN agencies receiving funding to work on sexual gender based violence.  Indeed at that time it was virtually impossible to determine what was being done, where, by whom and with what funding.  In addition to calling for this to be addressed within the UN system, we called for a much more visible political commitment by national authorities to the problem and this, we are happy to say, is happening.  The Congolese government, in conjunction with UNFPA, the American Bar Association, UNDP, EUPOL and other important external organizations, has taken several steps to promote the enforcement of the 2006 amendment to the Congolese constitution which makes all forms of sexual violence punishable offenses.  Our Accelerated Plan also called for more intensified action with the uniformed services such as police and military and we, as well as others, now have programs to strengthen the awareness and capacities of national police to prevent and aid in the prosecution of rape.  Another suggestion put forth called for a strengthening of the health care system so it could better respond to the needs of survivors.  Typically, victims of rape have little or no recourse to health care and are forced to deal with their injuries on their own.  In addition, we proposed a major thrust to strengthen the national judiciary system including training and organizational reform and there is good reason to believe that progress is being made on this at different levels. Our assessment of the situation highlighted the fact that a much more robust national surveillance and reporting system was necessary if national authorities and international organizations were to be able to monitor and evaluate the situation.  Finally, because mass rape in the DRC, just as elsewhere, is facilitated by the confusion and chaos that comes with the forced uprooting of people as a result of conflict, we called for more consolidated protection of displaced women.

None of the steps we called for are simple or easy, especially on the scale needed in a country that is larger than Europe and in which police and military personnel are poorly paid and in many cases have not been paid at all in years.  But we believe that if the course of action outlined in the Accelerated Plan that we proposed were to be taken up by all partners it could provide the basis and the momentum required to reduce the number of rapes committed in the DRC and provide women and girls, who are the primary albeit not the only victims, the sense of security they deserve and have not had in over twenty years of violence.

______________________________

Manuel Carballo is the Executive Director of the International Centre for Migration, Health and Development; Jennifer Drummond and Daniel Williams are researchers at the International Centre for Migration, Health and Development

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• UN has failed Congo mass rape victims, says investigator (guardian.co.uk)
• OXFAM Calls Out UN for Escalating Rape Victims in Congo (waronterrornews.typepad.com)
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• Margaret Aguirre: One Remote Village, 4 Days, 250 Rapes (huffingtonpost.com)
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The forced displacement of the Roma

Manuel Carballo

The Roma have long been a pariah people. Poorly understood, highly suspect, and the subject of pervasive myths, the Roma of Europe have been persecuted and marginalised for centuries. The latest move on the part of the French authorities to forcibly displace and return over 700 Roma and destroy over 50 camps, is another example of the intolerance of European society, and the unwillingness of national authorities to look at social issues in an evidence-based way. Over the next few weeks and months, other countries in Europe may be tempted to follow the model that France has initiated. If they do, it will constitute one of the largest forced displacements Europe has seen since the Balkan War.

Jeff Pachoud/AFP/Getty Images

From a public health perspective, what is being done to the Roma in France is likely to have far-reaching repercussions. Many Roma are poor, and have become used to living in conditions of extreme deprivation. Because of this, many of them will have developed the diseases that come with chronic poverty, poor nutrition, overcrowding, and poor healthcare. Forcing the Roma to move again and returning them to locations and situations that they fled from before, will only worsen their health condition. Diseases of poverty are never resolved through forced displacement; on the contrary, they are often aggravated by it. Like refugees everywhere, many Roma will now be pushed into situations of even greater poverty, worse living conditions, and even less access to health care. They will be exposed to more disease-prone situations, and they will become all the more vulnerable to a host of old and new physical, psychological, and social problems. Unless action is taken to ensure the welfare of this population, and unless steps are taken to integrate rather than exclude the Roma, we may be on the threshold of yet another European man-made disaster.

Corentin Fohlen for The New York Times

Related Articles

• Hundreds of Roma Expelled from France: Humane Deportation or Xenophobic Slum Clearing? (humanrights.change.org)
• Roma in Europe: Persecuted and misunderstood (cnn.com)
• France pushes forward Roma deportations: ‘They are trying to get rid of us all‘ (The Guardian)
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Pakistan: Forced Displacement and Climate Change

Pakistan: Forced Displacement and Climate Change

Manuel Carballo

In the space of little more than 3 weeks, more than 5 million people in Pakistan have been displaced from their homes, their farms, their villages, their communities, and their livelihoods. Predictions are that over the course of the next few weeks, the situation could become even worse and hundreds of thousands more people could be displaced. It will be many months, or even years, before we are able to assess the full extent of the human wastage and damage done, but already a number of assumptions can be made that call for urgent action.

Mohammad Sajjad, Associated Press

The first of these assumptions is that many families will have been disrupted and that many community structures will have been disorganised. In the case of the current situation in Pakistan, this means that millions of families are being affected in ways that will make coping all the more precarious and that will limit the capacity of individuals and groups to begin the difficult, but necessary, process of recovery and reconstruction.

The second assumption is that most of the communities or locations where people are moving to, or being moved to,  are ill-prepared to deal with this influx of women, men, and children of all ages. The load this will place on the healthcare system in these locations will be huge, and it is unlikely that in the absence of massive external assistance, they will be able to respond to the needs of this new population of displaced people.

The third assumption that can be made is that within the ranks of these displaced people, many were already in poor health even before the crisis happened. Pakistan has never been a wealthy country, and as many as a third of its people were struggling to live on less than $1 per day. Malnutrition was widespread, tuberculosis was rampant, and malaria common. Maternal and infant death rates were among the highest in Asia, and life expectancy among the poor was very short. Many of the diseases and health conditions these populations suffered from, now risk being aggravated and spread to other parts of Pakistan.

Associated Press photo

From a psychosocial perspective, the process of displacement will also have affected millions of people in far-reaching ways. Many, irrespective of age or gender, will have been traumatised to such an extent that their capacity to cope will have been lessened. Losing homes, farms, communities, and local cultures will inevitably have introduced a sense of hopelessness and despair that could debilitate the capacity to cope and prepare for a new life. Tragically, there is also reason to believe that the incidence of rape and other forms of gender-based violence will have gone up as well.

All these problems will be made worse by the fact that many of the people concerned are poorly educated and unfamiliar with disease prevention principles and with the healthcare systems that hopefully will become available to them in the coming months. Unless comprehensive and well-coordinated relief and recovery programmes are put into place quickly, Pakistan could be faced with a complex range of new and worsened old health problems.

Tragically, the crisis in Pakistan may be a foretaste of things to come on an equally large scale, and over a wider geographical region. For no matter what global warming and climate change is due to, the fact remains that extreme weather conditions, including heavy and seasonally unpredictable rains, are becoming more common in some parts of the world, while in others, extreme drought and lack of water are becoming common.

K.M.Chaudary/Associated Press

The response to the crisis in Pakistan has been slow in coming. Even now, it is clear that more funding is being proposed from the World Bank, the International Monetary Fund (IMF), and regional banks, than is coming from voluntary contributions. These loans will have to be paid back, and for the foreseeable future, Pakistan will move into a process of long-term indebtedness that will undermine the country’s economy even more so, and place vast numbers of people into greater poverty.

If the international community cannot respond in a more forceful fashion than it has done to date, this will bode ill for Pakistan’s people and their health. It will bode equally ill for all the other countries and the hundreds of millions of people who could be exposed to equally disastrous climatic events in the future.

Related Articles

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Shifting the Burden of Shame: Justice for Survivors of Sexual Violence in the DRC

“If they hadn’t arrested me I wouldn’t have known it was a crime”

~Chance, a soldier in the DRC currently serving a 25 year sentence for rape

“I was hospitalized at the health centre. I was receiving an IV infusion one night when the soldiers came to pillage. They pulled out the IV catheters and then they started to rape the patients, including myself. By July, I had not had my period for seven months. I gave birth to twins. As a result of this incident, my husband has abandoned me.”

“In our village, there was a lot of suffering because of the soldiers. For this reason, we were no longer sleeping in our houses; instead we were hiding in the bush. We were in our hiding place and I was sleeping. I saw five assailants coming. They were shameful enough to rape me. I am old – around 70 years of age.”

“Because our village was at risk of being attacked, my husband and I were sleeping in our hiding place. During the night in question, 30 well-armed assailants dressed in military uniform attacked us. They killed my husband. They tied me up and the child I was carrying on my back fell to the ground. A total of nineteen assailants took turns raping me.”

“My husband and I were sleeping in our house. The children were sleeping in the house next door. The soldiers arrived and brought my daughter to our house where they raped her in the presence of my husband and me. Afterwards they demanded that my husband rape my daughter but he refused so they shot him. Then they went into the other house where they found my three sons. They killed all three of my boys. After killing them, two soldiers raped me one after the other.”

“I was walking along the road near the Kamaguana market when a boy from my neighborhood called out to me. I thought he wanted to tell me something since he was a brother of my community. I approached him and he immediately pushed me into the yard and closed the door behind me. There was a man behind the door and he beat me very badly. Then he raped me and since it was my first sexual encounter, he took my virginity.”

~Quotes from “Now the World is Without Me”, a report by the Harvard Humanitarian Initiative, April 2010

A Congolese woman recovers at a hospital in Goma, DRC. Photo: Endre Vestvik (flickr)

While Sexual Gender Based Violence (SGBV) has been experienced by women and men during conflicts throughout history, it is only in the past 10 years that SGBV has been defined as, and declared, an international human rights issue. Previously, rape was considered an incidental spoil of war, or was used as a tool to boost morale, but people are now being targeted purely for political and strategic reasons.

The accounts and estimated numbers of victims of sexual violence since the beginning of the conflict in the DRC in 1996, have been widely publicized, though the estimates do not even scratch the surface of the real situation due to overwhelming underreporting of the offenses.  Widespread human rights violations in the form of sexual violence have been reportedly perpetrated by members of all military and militia groups involved in the conflict. From the beginning of the war until 2005, over 20,000 incidents of sexual violence requiring medical attention were reported. It is important to note that these reports were of emergency cases of traumatic fistula and other extreme injuries that required immediate medical attention only, and therefore the actual numbers are presumably much higher. During 2003, South Kivu health centers reported an average of 40 rapes per day, and 13% of those occurred in girls under 14 years of age.  In 2007, the UN reported an average of 350 cases per month in North Kivu province, and 2,773 rapes were reported in one region of South Kivu. The ages of the women and girls assaulted range from 10 months to 80 years old.  In several cases, local medical centers have been raided by the military and Viagra is distributed amongst the combatants to aid in these assaults.  The rapes are frequently disgustingly brutal with most rapes perpetrated by gangs.  Families are often forced to watch or participate in the rapes, and many women are raped with pieces of wood, cassava stalks or gun barrels, among other implements. There are also many reports of women being shot in the vagina.  As a result of such brutal violence, approximately 10-12% of the survivors reporting rapes have contracted HIV as a direct result of the assault.  In addition to physical consequences, those who survive sexual violence in the context of war, are also subject to intense stigma, blame, rejection by their community and loved ones and loss of possessions, livelihoods and traditions. The fear, shame and demoralization resulting from this violence not only affects the survivor, but the entire community.

© Unjin Lee / afrol News- Two Congolese rape survivors, both HIV positive, in a small clinic in Luvungi

One of the most immediate barriers keeping sexual violence survivors from healing in these combat situations is the lack of prosecution for offenders. This impunity is often the result of a failed judicial system and state, as well as the cultural bias and stigma associated with rape within the society, especially in the case of the rape of men and boys.  This stigma, as well as the fear of further violence if the survivor seeks medical care or reports the incident, leads to a dangerous silence that serves to perpetuate impunity. Furthermore, sexual violence is often not reported, especially in the eastern regions of the country, because most rural areas have little to no police presence, and many of the existing police forces are not properly trained to accept reports of sexual violence.  Additionally, many of these crimes are perpetrated by men and women in uniform. Further barriers to accountability include the failure to prevent attacks, inadequate support of effective prosecution efforts, and difficulty in documentation procedures due to an inability to collect timely evidence in conflict situations.

Excerpt from public records on sexual violence http://www.womensrightscoalition.org/site/advocacyDossiers/congo/tablesexualviolence_en.php

Since the beginning of these atrocities, and amidst all reporting that did take place, 2009 saw the first 5 men to ever be convicted and sentenced for the crime of mass rape. Currently, there are only about 300 inmates incarcerated in the North Kivu capital of Goma that have been accused or convicted of rape.  The lack of accountability and culture of impunity, and the publicity surrounding the impunity, only serves to propagate these brutal crimes and to further the psychological impact on survivors and their communities.  Additionally, this same culture of impunity has been cited as one of the main reasons behind a recent increase in rapes perpetrated by civilians. While sexual violence in the East is still largely militarized, a recent study by the Harvard Humanitarian Initiative has shown a marked increase in civilian sexual predators. In 2004, for example, less than 1% of rapes were perpetrated by civilians, compared to 38% in 2008.

In an effort to aid in the provision of justice for survivors of sexual violence, ICMHD is currently involved in a security sector reform project to train members of the national police force to work with the reporting and prosecution of sexual violence. This training program not only addresses practical skills such as investigatory and interview techniques, but also addresses the culturally-related thoughts and actions concerning sexual violence against both women and men. Protection of those who report and testify is a main focus of these training modules, as well as the need to treat all perpetrators as equals regardless of social or military status. The education of those mandated to protect civilians is merely one step in the fight against sexual violence and impunity. The civilian population must be educated in the same manner. To be able to create behavioural change, it is absolutely necessary that the burden of shame be placed on the perpetrator and not on the survivor. Only with justice that can be ‘seen’ will healing for survivors begin. Without justice that can be seen, the rampant sexual violence currently being endured will continue.

References and Links

Harvard Humanitarian Initiative Report   Now, The World Is Without Me: An Investigation of Sexual Violence in eastern Democratic Republic of Congo

“Our Bodies- Their Battle Ground: Gender-based Violence in Conflict Zones.” IRIN. United Nations Office for the Coordination of Humanitarian Affairs. September 2004. Retrieved from http://www.irinnews.org/pdf/in-depth/GBV-IRIN-In-Depth.pdf.

Couldrey, Marion and Tim Morris, Eds. “Sexual Violence: Weapon of War, Impediment to Peace.” Forced Migration Review. Refugee Studies Center. January 2007     Retrieved from      www.fmreview.org/sexualviolence.htm

“DRC: Special Report on War and Peace in the Kivus.” IRIN. United Nations Office for the Coordination of Humanitarian Affairs. August 6, 2004. Retrieved from http://www.reliefweb.int/rw/rwb.nsf/AllDocsByUNID/255867dccca8df71c1256ee8003eec46.

“No End to War on Women and Children. North Kivu, Democratic Republic of the Congo.” Amnesty International. Amnesty International Publications. September 29, 2008. Retrieved from http://www.amnesty.org/en/library/asset/AFR62/005/2008/en/bbe6934a-9f60-11dd-9e51-afa0a8282a50/afr620052008en.pdf.

“DRC: Rape cases soar in South Kivu.” IRIN. United Nations Office for the Coordination of Humanitarian Affairs. June 3, 2009. Retrieved from http://www.irinnews.org/report.aspx?ReportID=84685

DRC: Behind Bars for Rape. Retrieved from http://www.irinnews.org/Report.aspx?ReportId=89761

DRC:Getting Away With Rape. Retrieved from http://www.irinnews.org/Report.aspx?ReportId=89802

Analysis: Rethinking Sexual Violence in DRC. Retrieved from
http://www.irinnews.org/Report.aspx?ReportId=90081