The link between food security and mental health is well recognised.
The Inter Agency Standing Committee Guidelines on Mental Health and Psychosocial Support in Emergency Settings make clear that ‘understanding the interactions between psychosocial well-being and food/nutritional security enables humanitarian actors to increase the quality and effectiveness of food aid and nutritional support programmes while also supporting human dignity’. The 2019 Food security and nutrition in the world report noted that ‘food insecurity is associated with poorer mental health and specific psychosocial stressors across global regions independent of socio-economic status’.
What urgently requires more attention is how this relationship between food security and mental health is becoming entangled with the effects of Covid-19.
The From the field project is an ongoing multidisciplinary, global research collaboration seeking to explore the impact of the virus on the lives and livelihoods of Syrians in the country and the wider region. Its findings are highlighting the dynamic nature of the virus’ consequences for displaced Syrians and confirming the need for a broader view of its multi-layered effects on the most vulnerable.
Food security and mental health
Numerous factors threaten food security across the Middle East. Climatic conditions and devastating conflict have damaged the socioeconomic institutions underpinning regional food systems. At the same time there has been a concerning trend away from diets traditional to the region in favour of cheaper, processed foods with higher levels of salt and sugar, leading to inadequate nutrition and increases in related non-communicable diseases, such as cardiovascular disease and diabetes.
The region’s prospects of meeting its targets and indicators under Sustainable Development Goal 2 on hunger are now precarious. The outlook for the region is worrying, with the prevalence of undernourishment projected to almost double, from 24.3 million in 2005 to 42.1 million by 2030.
Some 9.3 million Syrians are currently considered food-insecure in their home country. There has been a three-fold increase in the proportion of surveyed Syrian households reporting poor food consumption since May 2020.
In neighbouring countries, 5.6 million Syrians who have been forced to migrate due to the conflict also struggle to meet their food needs. Prices for food and non-alcoholic beverages in Lebanon increased by 367% between August 2019 and August 2020, and a multi-agency assessment in April of this year found that 32% of households in Jordan reported not having had enough to eat in the previous week.
The region is also characterised by rising levels of mental health conditions. Data from the Global Burden of Disease Index shows that the rate of Disability-Adjusted Life Years (DALYs – the number of years lost due to ill-health – due to depressive and anxiety disorders has been increasing over the last two decades (see Figure 1).
The mental health and psychosocial wellbeing of the Syrian population specifically has been of central concern. Syrians experiencing conflict have been exposed to a number of risk factors for mental health, including traumatic or violent events, forced multiple displacements, unresolved grief, disruption to meaningful activities, breakdown of social roles, loss of social support and persistent daily stressors, such as poverty, overcrowded shelters and inadequate access to food.
Prevalence rates of mental health conditions vary but the overall picture is clear. Syrians are exhibiting elevated levels of mental ill-health, in terms of depression, low subjective wellbeing and anxiety. One recent systematic review of 8,176 Syrian refugees resettled in 10 countries reported a prevalence rate of 40% for depression and 26% for anxiety.
From the field – identifying local patterns
Since April 2020, thanks to funding from the Global Challenges Research Fund, the From the field project has been active as a multidisciplinary, global research collaboration seeking to explore the impact of the Covid-19 virus on the lives and livelihoods of Syrians living in Lebanon, Iraqi Kurdistan, Jordan, Syria and Turkey.
Syrian academics and researchers from the University of Edinburgh and the NGO Council for At-Risk Academics (Cara) Syria Programme co-created and deployed 100 questionnaire surveys, comprising mental health scales and food security measures, through local researchers and practitioners. Participants were selected on the basis of having originally come from a rural area, and most still work in agriculture or food production, even if they now live in urban areas. Our sample was predominantly male (75%) and in their mid-thirties.
In the sample, the overwhelming majority, 98%, had employed some form of coping strategy to manage their food intake in the previous seven days, including limiting portion size or reducing the frequency of meals. Over half – 52% – were adopting four or more coping strategies combined.
The study also indicated that just over a fifth of participants was experiencing thoughts and emotions consistent with depression or anxiety. Many reported being unable to relax, not feeling useful and being unable to think clearly. A significant number were not hopeful for their future.
Our data confirmed the pre-existing literature on the association between food security and mental wellbeing: of the Syrians surveyed, those who were more food secure were also demonstrating higher levels of mental wellbeing; the greater the number of coping strategies being adopted, the lower the level of mental wellbeing.
The impact of Covid-19 was clearly placing an additional burden on mental health. Many individuals opened up in the margins of our surveys to speak of the high level of stress and exhaustion they were experiencing as public health restrictions increased domestic demands and the economic pressures on households, and schools were unable to provide education for their children. At the same time there were reports of tedious boredom and familial tension in overcrowded living spaces. There were growing expectations in the home around food preparation and cleanliness, which was typically falling on the household’s women, just as economic pressures were limiting what was available to prepare.
Responding to a syndemic
It is argued that Covid-19 is not a pandemic but rather a ‘syndemic’. A syndemic is characterised by ‘biological and social interactions between conditions and states, interactions that increase a person’s susceptibility to harm or worsen their health outcomes’. In this case, an infectious disease, Covid-19, is interacting with social disparities and inequalities worldwide to aggravate the prevalence of numerous non-communicable diseases, including issues of mental health concern.
In our project we have seen how Covid-19 is interacting with the mental health and food security of displaced Syrians. As Figure 3 outlines, mental health and food security are already in a complex relationship but the effects of Covid-19 are magnifying the consequences each has for health and psychosocial wellbeing.
This infectious disease and the societal effects associated with it can create multiplier effects between these different factors that ultimately lead to the depletion of an individual’s immunological defences against the virus. Positive mental health and adequate nutrition are well-established as significant contributors to the body’s capacity to defend itself against viral infection.
Emerging evidence indicates that there is a set of neuropsychiatric effects associated with contracting Covid-19, with increased risks of cognitive decline and other neurodegenerative conditions such as Parkinson’s disease and Alzheimer’s disease, as well as other mental health issues like depression, anxiety and Obsessive Compulsive Disorder.
Responses to Covid-19 which do not consider the full breadth of its effects will not only fail in addressing a wider set of public health concerns, but also risk leaving people even more at risk from the virus.
One key lesson from another outbreak emergency, the West Africa Ebola crisis, was that the management of the crisis should have had a broader response base from the outset. Unfortunately, it was concluded that ‘wider implications – for instance for food security, livelihoods and education – were neglected, and NGOs were unclear on how or where to engage. A narrow focus on Ebola also downplayed other health implications, and people with other conditions were left without treatment’.
How do we act in response to a syndemic in which there is such a complex interplay between food and mental health?
The Food and Agriculture Organization’s report Food security and nutrition: building a global narrative towards 2030 has called for an update to the standard conceptual framework of food security, which concentrates on access, availability, utilisation and stability, to include two new criteria: ‘agency’ and ‘sustainability’.
Agency refers to ‘the capacity of individuals or groups to make their own decisions about what foods they eat, what foods they produce, how that food is produced, processed and distributed within food systems, and their ability to engage in processes that shape food system policies and governance’. ‘Sustainability’ refers to ‘the long-term ability of food systems to provide food security and nutrition in a way that does not compromise the economic, social and environmental bases that generate food security and nutrition for future generations’.
This person-centred, rights-based approach to food security, which takes into consideration the longer-term, environmental factors supporting food systems, is welcome. It should imply a recognition that positive psychological wellbeing of individuals facing humanitarian crisis is required for robust food security.
The first critical step towards ensuring greater agency and sustainability is to listen to how Syrians are experiencing this syndemic, to understand their experiences and harness their expertise to shape our interventions.
The From the field project has placed Syrian researchers at the centre of the design and implementation of the study. Syrian academics in exile offer a wealth of local knowledge, connections and expertise. This major part of Syria’s intellectual and cultural capital has been largely neglected by the intelligence-gathering and analysis activities informing humanitarian responses to the crisis. This collaborative approach has led us to these essential links between food security and mental health as they have manifested among Syrians, and reminds us that we must retain a focus on the non-communicable diseases that can proliferate under the cover of Covid-19.
Funding appeals will increase to meet growing needs. However, in many cases tackling some of the most egregious effects of this syndemic will not require doing more but doing things differently, through the establishment of complementary programmes that create connections between interacting sectors. For instance, evidence is emerging of the benefits of prolonged multipurpose cash assistance in reducing food insecurity and improving mental health. This is encouraging and points towards the need to explore the possibilities of ‘Cash Plus’ programmes that can provide parallel, linked mental health and psychosocial services.
Two key dates in the global calendar are just a week apart: World Mental Health Day, on 10 October, and World Food Day, on 16 October. This year the theme for the latter is: ‘Grow, Nourish, Sustain. Together’, but the sentiment stands equally well for both.
The From the field project is SFC-GCRF Covid-19 supported research exploring the impact of Covid-19 on UN Sustainable Development Goals in humanitarian settings. It will feed into the GCRF-funded Syrian Food Futures project, as part of work by the University of Edinburgh-led Network of Expertise on Food and Health Security in Fragile and Conflict Affected States, in collaboration with the Cara Syria Programme. For more information see https://www.ed.ac.uk/global-agriculture-food-security/research/data-driven-innovation/food-security-in-fragile-and-conflict-affected-sta
Joseph BURKE, Researcher, School of Health in Social Science, University of Edinburgh
Dr. Shaher ABDULATEEF, Cara Syria Programme & University of Edinburgh
Prof. Lisa BODEN, Chair of Population Medicine and Veterinary Public Health Policy, University of Edinburgh
Dr. Clara CALIA, School Deputy Director of Research Ethics & Integrity. Lecturer in Clinical Psychology, School of Health in Social Science, University of Edinburgh
The authors would like to thank the From the field team who have contributed in various ways to this research, including Joy Abi Habib (Mental Health Specialist, Lebanon); Maria Azar (Clinical Psychologist, Lebanon), Professor Liz Grant (Professor of Global Health and Development/Director Global Health Academy, Usher Institute, University of Edinburgh), Dr Suk-Jun Kim (School of Language, Literature, Music and Visual Culture, University of Aberdeen), Mackenzie Klema (Researcher, Global Academy of Agriculture and Food Security, University of Edinburgh), Dr. Stella Mazeri (Epidemiologist, The Roslin Institute, University of Edinburgh), Kate Robertson (Cara Syria Programme) and Dr Ann-Christin Zuntz (Anthropologist of Development, University of Edinburgh).