Mental health and conditions in refugee camps matter when Rohingya living in Bangladesh consider returning to Myanmar

For several decades Rohingya in Myanmar have lived in an environment of increasingly severe systematic human rights violations, including the removal of citizenship and restrictions on movements, limited access to education and healthcare, and barriers to marriage, having children and practicing their religion. In August 2017 Myanmar security forces completely or partially destroyed almost 400 Rohingya villages, and killed, injured and sexually assaulted several thousand Rohingya. This violence sparked an exodus of 700,000 refugees from Myanmar to Bangladesh. The long-standing systematic human rights violations, including the nature and scale of the violence against the Rohingya, have been well documented by human rights organisations and the United Nations.

In addition to historical human rights violations, including violence experienced in Myanmar, Rohinya refugees now have to cope with difficult living conditions in the refugee camps in Bangladesh. As has been reported elsewhere, challenges in the camps include movement restrictions, lack of livelihood opportunities, difficulties fulfilling basic needs, safety concerns, and limited access to services such as healthcare and education. In recent months conditions have worsened as a result of Covid-19 and associated measures to slow transmission, alongside seasonal extreme weather events causing flooding and related difficulties. A history of violence and systematic human rights violations in Myanmar, as well as daily stressors associated with the difficulties of refugee life in Bangladesh, have contributed to mental health challenges. This includes high levels of depression, anxiety, post-traumatic stress disorder (PTSD), anger, psychosomatic symptoms and suicidal ideation.Unfortunately, there are barriers to addressing population-level mental health needs due to resource constraints and other challenges – such as a lack of trained mental health personnel that can speak the Rohingya language – which results in a lack of scalable culturally appropriate interventions For more on this, see the Special Issue of Intervention on Rohingya mental health. .

As the scale of the Rohingya refugee crisis has increased in recent years, pressure has been building to find durable solutions. To date, the primary focus has been on repatriating Rohingya refugees to Myanmar; however, as many stakeholders have indicated, conditions are not yet conducive to a safe return. Despite this, Bangladesh and Myanmar agreed to a controversial repatriation framework, with plans put in place to return the initial group of families without adequate consultation with the community or UNHCR. Since the Myanmar military coup d’etat in February 2021, these repatriation plans have been regarded as inappropriate in the current political climate, making discussions regarding the pre-requisites for a safe and voluntary return even more relevant.

Historically, Bangladesh has contributed to coercive practices during repatriation of thousands of Rohingya refugees. For example, in 1993 Bangladesh moved forward with repatriation efforts despite data indicating that the majority of refugees were unwilling to return. Given this history, it is not surprising that many in the refugee community are distrustful of the current process.

It is against this backdrop that, in 2018, the human rights organisation Fortify Rights began a participatory action research project involving a team of ten experienced Rohingya refugee researchers living in refugee camps in Cox’s Bazar District, Bangladesh. Using data collected by Fortify Rights in this article, we examine Rohingya opinions about repatriation, including prerequisites for return. In addition, we examine the relationship between mental health symptoms, daily stressors in the refugee camps in Bangladesh, and perspectives on repatriation.

The study and its findings

In July and August 2018, Fortify Rights conducted a cross-sectional, mixed methods research study in Cox’s Bazar, Bangladesh. A total of 495 Rohingya refugee participants were involved in the larger study. All data was collected by an experienced team of Rohingya researchers trained in data collection. Random sampling methods were used to select refugee households and individuals to ensure that survey results were representative of the broader Rohingya refugee population in Bangladesh. Results from this study have been published elsewhere, emphasising relationships between systematic human rights violations, traumatic events, daily stressors, mental health symptoms and functioning, but not including repatriation-related results. 

For the repatriation-related components of the study, refugees were asked on a scale from 1 (not at all) to 4 (extremely) to what extent they would like to return to Myanmar in the future. Additionally, respondents were asked to respond ‘yes’ or ‘no’ to a number of prerequisites they felt must be met to ensure a safe return to Myanmar (e.g., citizenship, reparations, freedom), including an open-ended, qualitative response option, allowing respondents to spontaneously share additional prerequisites. Refugee respondents were also asked (using the same 1-4 scale) about their perceptions regarding reintegration with the majority Rakhine ethnic group upon return to Myanmar.  

High levels of mental health distress were reported by Rohingya: As reported in associated publications, 61% of Rohingya endorsed symptoms typically indicative of PTSD and 84% endorsed symptoms of depression and anxiety – typically indicative of significant emotional distress. These symptom levels are significantly higher than expected following an emergency.

A majority of Rohingya refugees (95%) indicated that they want to return to Myanmar in the future. However, the desire to return was heavily qualified, with participants indicating that there are prerequisites that must be met in order for them to feel safe enough to return:

• 93% indicated that the Myanmar government needs to provide them with citizenship.
• 86% indicated that they require compensation for their losses (such as property damage).
• 75% indicated that physical protection is necessary (e.g., by U.N. security forces).
• 72% indicated a need for guarantees of specific freedoms (e.g., freedom of movement, ability to attend school).

Respondents also emphasised that they wished to see the Rohingya recognised as an official ethnic group in Myanmar (23%), wanted to see justice for past crimes (14%), and needed religious freedoms (9%).

A majority of Rohingya (78%) endorsed a willingness to reintegrate with the majority Rakhine ethnic group in Myanmar, despite a history of documented Rakhine involvement in the persecution of the Rohingya. Although 80% of Rohingya respondents thought that Rakhine people were responsible for restrictions levied against them in Myanmar, 66% of Rohingya indicated some degree of forgiveness for Rakhine involvement in abuses.

Findings indicate several factors that appear to influence attitudes towards repatriation among Rohingya refugees in Bangladesh, including mental health, current conditions in the camps and prerequisites that must be in place prior to return These findings are based on results from linear regression models. .

• Elevated depression and anxiety symptoms were associated with a desire to return to Myanmar in the future.
• However, those who experienced a higher number of traumatic or violent events in Myanmar had significantly lower levels of desire to return to Myanmar in the future.
• A higher number of reported difficulties in the refugee camps in Bangladesh predicted a desire to return to Myanmar in the future.

Return prerequisites were associated with mental health symptoms and current difficulties in the camps.

• Although refugees with more severe symptoms of depression and anxiety were more likely to want to return to Myanmar in the future, they had more demands prior to return (e.g., citizenship, reparations), than those with lower symptom levels.
• Greater difficulties in the camps (e.g., problems with food, water, shelter) contributed to a higher number of demands prior to return to Myanmar as well.

Recommendations

Here, we attempt to understand these results, and make associated recommendations for policy-makers and practitioners.

Recommendation 1: Those working with Rohingya, and other populations displaced as a result of civil conflict, should address mental health needs as a means of promoting a fully voluntary return process.

Decisions about returning to Myanmar appear to be influenced by untreated mental health needs. Those with more severe symptoms of depression and anxiety reported greater willingness to return. In addition to other mental health symptoms reported, a large number of those in the camps (77%) indicated that they felt ‘hopeless about the future’. Research has documented links between conditions in the camps and poor mental health. In contrast, those who experienced or witnessed more instances of violence in Myanmar were less likely to want to return. This could be linked to avoidance-related symptoms (common with PTSD). The vast majority (84%) of Rohingya respondents endorsed some level of ‘avoiding thoughts or feelings associated with the traumatic or hurtful events [they experienced]’. Additional research should attempt to better understand the relationship between trauma exposure, current systems, life in the camps and desire to repatriate.

Recommendation 2: Stakeholders working in Rohingya refugee camps should address shortfalls in services within the camps and limitations to human rights (e.g., movement restrictions) to ensure a more voluntary return process. This will not only minimise coercive elements but will also likely improve mental health.

Decisions about return to Myanmar appear to be influenced by difficulties fulfilling basic needs in the camps. UNHCR guidelines for repatriation emphasise that voluntary repatriation requires the ‘absence of direct or indirect coercion by the authorities of the countries of asylum or origin’ and that indirect coercion can include the maintenance of ‘dire conditions in refugee camps, or a denial of basic rights’. Over the past few years in particular, conditions in the camps have been challenging. For example, around the time of data collection, agencies were reporting health crises, flooding and limitations in available funding to address basic needs (the joint funding appeal in 2019 was only resourced at 70% of need).

Recommendation 3: Given the complex nature of repatriation decisions, stakeholders on all sides must redouble their efforts to include Rohingya in repatriation discussions.

Recommendation 4: Safety frameworks must be in place and basic human rights must be secured before Rohingya are expected to feel comfortable with repatriation to Myanmar.

Certain conditions are necessary before many Rohingya will feel comfortable returning to Myanmar. Respondents qualified their desire to return to Myanmar in the future, with a majority indicating a number of prerequisites. These expectations prior to return align with UNHCR and IOM guidelines on migration and voluntary repatriation and are in keeping with what human rights organisations have said on the topic. Furthermore, Crisp argues that ‘Quadripartite Commissions’ should be formed to include refugees in repatriation negotiations, alongside UNHCR and countries of origin and asylum. Given the current political climate in Myanmar,

repatriation plans and discussions regarding the pre-requisites for a safe and voluntary return are more relevant than ever.

By addressing mental health needs, mitigating coercive camp conditions resulting from resource limitations, including refugee voices in repatriation discussions, and ensuring an emphasis on safety and human rights in Myanmar as a prerequisite for return, Rohingya can make more voluntary decisions about repatriation.

Andrew Riley is a Rights-Focused Researcher. 

Yasmin Akther is a Research Consultant.

Mohammed Noor is an Independent Researcher.

Fourth Author (Name/Organisation redacted for security reasons).

Courtney Welton-Mitchell is with the Colorado School of Public Health and Institute of Behavioral Science, Natural Hazards Center, University of Colorado.