Why inclusive mental health support should continue to be integrated into humanitarian aid towards Arab countries now more than ever: a brief overview
by Hiba Abdullah
Part 1: The current situation and legislation
The attitudes, treatment, and general view towards mental health disorders have been a slow, but continuous journey in the Arab region, just like that of the rest of the world. Mental health disorders can incapacitate individuals by interfering with their daily lives to varying extents, impacting everything from physical health and economic opportunities, to social interactions and development (International Medical Corps, p. 1).
According to Lesley Pocock (2017):
“Issues of war and violence, displacement, refugees, occupations by militia and terrorists, restrictions on women in traditional societies, arranged and forced marriages, lack of tolerance for gender dysmorphia, and domestic violence are causing mental health problems such as PTSD, depression, anxiety, and suicide (i.e. affective disorders) and are contributing to the psychological and sociocultural causes of mental health disorders in the region (p. 10).”
Though these are issues faced in various parts of the world, mental health disorders are “a leading cause of disability in the Arab region”, the latter making up around 5.54% of the global population and facing a “higher burden of mental disorders than that of the global population” (Maalouf et al. 2019, p. 961). The region has a total population of 425 million and one of the largest proportions of young people in the world – around 60% of Arabs are below 25 years old (Ibid).
According to Okasha et al. (2012), as of 2012, “out of the 20 countries for which information is available, six do not have a mental health legislation and two do not have a mental health policy” (p. 52). In 2007, Lebanon, Kuwait, and Bahrain had more than 30 psychiatric beds per 100,000 people, while Sudan and Somalia had less than 5 per 100,000 (Ibid). The highest psychiatrist-to-individual ratio was in Qatar, Bahrain, and Kuwait, whilst Iraq, Libya, Morocco, Somalia, Sudan, Syria, and Yemen had the lowest ratios – less than 0.5 psychiatrists for 100,000 individuals (Ibid). The budget allocated for mental health services in the health budget – in the few countries where this information is available – is overall “far below the range to promote” and maintain sufficient and effective mental health support (Ibid). Though some improvements have been made in the last decade, the attention and resources allocated to issues relating to mental health are still insufficient (Ibid).
This information, however, is outdated. Arab countries contribute to “only 1% of the global output for peer-reviewed publications in mental health research” (Maalouf et al. 2019, p. 961). Numerous stakeholders – including “Arab mental health researchers, institutional and funding agency officials, and international research collaborators” – have attempted to establish the many challenges limiting mental health research in the Arab world, and their findings included:
Prevalent stigma and low awareness, conflict and war, scarce institutional and funding resources, inadequate publishing opportunities, insufficient training in mental health research, and shortage of reliable and valid assessment tools (Ibid).
It should be noted that the Arab region was once at the forefront of mental health care, as the first psychiatric hospitals are believed to have been built in Baghdad and Cairo during the 8th century, where treatments like occupational and music therapy were employed (The Economist 2016). Nonetheless, when looking at the past 10 years, the region’s degree of research productivity has increased by 160% (Maalouf et al. 2019, p. 961).
The list goes on, and does not stop at the unavailability of resources; “even when therapy is available, many refuse it because of the stigma” (Ibid).
Part 2: Why appropriate and inclusive mental health support is important now more than ever
With the escalation of the coronavirus pandemic (COVID-19), as well as the continuation of wars and armed conflicts across the Arab region, Arabs – as well as marginalized ethnic and religious groups across the region – have to deal with the financial, physical, social, domestic, and educational effects presented by the pandemic alongside their daily struggle or oppression, which in turn adds a serious burden on mental health both in the short and long term. Severe long-term mental health disorders – such as PTSD and depression – are furthered as the pandemic presents the insecurity of an uncertain future coupled with social isolation, deepening existing vulnerabilities. According to the International Medical Corps:
in emergencies, people with pre-existing mental health problems are often dependent on care and assistance from others and may be left without the appropriate care. They are also more vulnerable to injuries, discrimination, violence, abuse, and human rights violations (p. 2).
Take Gaza for instance, where the population is currently faced with COVID-19 alongside issues of “domestic violence, economic blockade, and ongoing conflict” (Abu Jamei 2020). According to Abu Jamei (2020), “people were already facing huge mental pressures” before the pandemic hit, primarily from “crushing poverty” caused by an economic blockade and “extreme fear” and trauma from frequent military escalations and three wars (Ibid). Now, of course, Palestinians residing in the occupied West Bank and Gaza Strip have no control over their jurisdiction, as do any other people living under occupation by tyrannical or oppressive systems, such as Syrian civilians. However, humanitarian aid in the form of psychosocial support by NGOs and non-profit organizations has become instrumental in creating a system of restorative mental health services to handle pre and post COVID-19 mental health issues when public policymakers cannot be relied on. Networks such as the Mental Health Network can even create a system of organizations that can supplement humanitarian aid. Only when initiatives are appropriately and evenly established in all communities in affected countries, will an adequate mental health system be built, overall increasing the accessibility for individuals to receive the support needed to deal for their traumas from before and after COVID-19.
Fortunately, there has already been some improvement since the beginning of COVID-19. According to UNICEF’s 5th Situation Report (2020), “almost 18,000 children and parents/caregivers were provided with mental health and psychosocial support throughout the region […], with a focus on vulnerable populations” (UNICEF 2020, p. 4).
Keeping in mind the uncertainty that COVID-19 brings, the delivery of remote mental health support should also be considered in areas with access to the internet and a computer. In Egypt, a Facebook page offering support and mental health-related information on COVID-19 was created by a partner of UNHCR in six different languages (UNHCR 2020, p. 4). UNHCR Iraq’s additional contributions to the Facebook group have even enabled the availability of four more languages, including Kurdish (Ibid). Increasing language accessibility leads to reaching more non-Arabic speaking minorities. This is important because humanitarian aid that is inclusive of minority groups is instrumental in ensuring that all residents and citizens of Arab countries are provided with appropriate mental health support.
Looking at countries with increased reports of domestic violence due to COVID-19’s quarantine confinement, Lebanon has seen a “spike in instances of self-harm and harm to others” as well as an increase in “family disputes, domestic violence, and divorce cases” (UNHCR 2020, p. 1). According to the UNHCR (2020), individuals at highest risk of domestic violence are family members and children –particularly women and girls (Ibid). The incorporation of inter-agency coordination has already been put to action through group sessions and activities hosted on WhatsApp, by “identifying and managing emotions”, as well as targeting men and boys “in terms of management of stress and anger behavior that not only intends to prevent violence, but also attempts of self-harm” (UNHCR 2020, p. 7).
Finally, I would like to look at the impact of COVID-19 on the elderly populations in the Arab region. Generally speaking, Arab countries are not very resourced or experienced in geriatric psychiatry (El Hayek et al. 2020, p. 7). However, El Hayek et al. (2020) argues that this population is vulnerable and should thus “be taken into consideration, particularly during the COVID-19 situation” (Ibid). With shifting demographics in the Arab region come evolving family dynamics in terms of labor opportunities; more parents are working abroad, leaving their children in the care of their grandparents (Ibid). An implication of this is, “should grandparents become infected or succumb to illness”, their dependent grandchildren will in turn be impacted (Ibid). Additionally, self-isolation can severely affect mental health in older adults, whose social contact is typically outside of their homes – such as in places of worship or community centers (Ibid).
Since a large part of healthcare services in the Arab region have been significantly limited by COVID-19, they are unlikely able to provide the needed psychosocial care that vulnerable individuals – a large part comprising of elderly individuals – would receive, furthermore ensuing in the “marginalization of the geriatric population” (Ibid). Therefore, appropriate and inclusive mental health support is important now more than ever because social isolation among older adults would “become associated with considerable morbidity and mortality secondary to cardiovascular and neurocognitive complications and mental health problems” (Ibid).
To supplement the initiatives already taken by humanitarian and not-for-profit organizations and networks to tackle mental health issues furthered by COVID-19, a strong foundation of inclusive mental health research and services should be implemented in any humanitarian aid provided by NGOs in Arab countries in order to alleviate the long-term mental effects present before the inception of COVID-19. A brief overview of steps that can be taken has been compiled by Maalouf et al. (2019), presented below.
Part 3: A proposed multi-sectoral action plan (compiled by Maalouf et al. 2019, p. 963)
Spread awareness and address stigma
• Educate patients and their families about mental illness
• Raise awareness among the public, especially young people (e.g. via school and university-based platforms)
• Use social media
• Engage religious leaders
Increase collaborative research of mental health
• Increase regional collaborations (i.e. Arab Regional Center for Research and Training)
•Increase multidisciplinary collaborations, particularly during development of Arabic instruments (e.g. subject-matter experts, psychometrists, cross-cultural psychologists, and linguists)
• Increase funding support for international collaborations (e.g. Fogarty International Center, Academy of Medical Sciences, Harvard Medical School Center for Global Health Delivery—Dubai, and the Welcome Trust)
Strengthen infrastructure of regional research
• Establish Institutional Review Boards
• Develop and fund entities to support core research functions (e.g. clinical research institutes)
• Invest in independent academic institutions in the region (e.g. schools of public health)
Strengthen the mental health workforce
• Ensure that medical students have adequate exposure to psychiatry and introduce postgraduate training programs in psychiatry and clinical psychology.
Translate research findings into action on societal and governmental levels
• Engage stakeholders in prioritising, doing, and translating research.
• Communicate findings to governmental advisors and officials, including policymakers beyond the health sector.
• Disseminate findings to the public (e.g. through conventional and social media platforms)
• Share findings with mental health professionals as well as other health-care professionals (e.g. at local conferences) who would help with advocacy efforts.
Hiba is a student at the University of Edinburgh
Abu Jamei, Y. (2020, June 11). ‘How do we protect mental health in Gaza during the COVID-19 pandemic?’ Trócaire News. Retrieved from https://www.trocaire.org/news/how-do-we-protect-mental-health-gaza-during-covid-19-pandemic
Afana, A. H., Qouta, S., & El Sarraj, E. (2004). ‘Mental health needs in Palestine.’ Humanitarian Exchange, 28.
International Medical Corps. (rep.). Addressing Mental Health in Humanitarian Crises, 1–4.
Hayek, S. E., Cheaito, M. A., Nofal, M., Abdelrahman, D., Adra, A., Shamli, S. A., … Sinawi, H. A. (2020). ‘Geriatric Mental Health and COVID-19: An Eye-Opener to the Situation of the Arab Countries in the Middle East and North Africa Region.’ The American Journal of Geriatric Psychiatry, 1–12. http://doi.org/10.1016/j.jagp.2020.05.009
Maalouf, F. T., Alamiri, B., Atweh, S., Becker, A. E., Cheour, M., Darwish, H., … Akl, E. A. (2019). ‘Mental health research in the Arab region: challenges and call for action.’ The Lancet Psychiatry, 6(11), 961–966. http://doi.org/https://doi.org/10.1016/S2215-0366(19)30124-5
‘Mindfield; Mental health in the Middle East.’ (2016, May 21). The Economist, 419 (8990).
Pocock, L. (2017). ‘Mental Health Issues in the Middle East: An Overview.’ Middle East Journal of Psychiatry and Alzheimers, 8(1), 10–15. http://doi.org/10.5742/mepa.2017.93004
UNICEF. (rep.). Middle East & North Africa Region: COVID-19 (pp. 1–22). Retrieved from https://reliefweb.int/sites/reliefweb.int/files/resources/UNICEF MENARO COVID-19 Situation Report No. 5 – for 15-31 May 2020.pdfUNHCR. (2020). (rep.). Mental Health and Psychosocial Response during COVID-19 Outbreak, 1–8.