Dr Chhabilall Timsina (Sharma) is originally from Gaylephug Bhutan. He worked in Bhutan as the District Medical Officer . After he became a refugee, Dr. Sharma worked for eight years with the Save the Children (UK), and UNHCR in Nepal, caring for Bhutanese refugees. He completed his psychiatry residency at Hennepin- Regions Psychiatry Program, Minnesota in 2011, where he served as Chief Resident . He is currently Board Certified psychiatrist working for Health Partners, and spends part of his clinical time at Health Partner’s Center for International Health taking care of refugees and immigrants. Dr. Sharma is recently been appointed by University of Minnesota as Global Health Faculty (as Nepal Site Director).
In an attempt to bring out more detail picture about the alarming suicides among the resettled community, BNS talked to Dr Sharma. Here is what he has to say about the issue and probable measures of solution:
You have long served as a medical professional in Bhutan as well as in exile; can you share about the overall health condition of Bhutanese Community?
After graduating from Kanpur Medical College in India, I worked for about 8 years in Bhutan from 1984 to 1992. I worked in Bumthang, Thimphu, Chirang, and Wangiphdrang districts. I initially started as General Duty Medical Officer and then was promoted to District Medical Officer with the responsibility of managing the district level hospitals and advising and supervising other medical establishments in the districts. Ours was a country at a very early stage of modern development with low level of literacy and limited infrastructural facilities and amenities of living. However, we had great faith in our capacity to improve and there was great enthusiasm and goodwill among all people. Our capacity and sophistication of services was limited and accessibility to care was constrained by lack of awareness and geographical distance and terrain. People in Bhutan suffered from the following diseases:
- Respiratory illnesses due to smoke-filled houses with wood burning stoves without vents and in some cases, smoking. Upper respiratory infections, bronchitis and pneumonia were very common. Pulmonary tuberculosis was also very prevalent.
- Diarrheal Diseases were common due to lack of safe drinking water and open space defecation.
- Skin, eye, and ear infections
- Measles, mumps, chicken pox, and diphtheria
- Malaria, meningitis, and encephalitis
- Obstetric, surgical, and medical emergencies
- Malnutrition, anemia and iodine deficiency
When our people were persecuted by the government of Bhutan for demanding their cultural, religious, and citizenship rights, several thousands were beaten up, arrested, tortured and imprisoned. I provided medical care for people who were detained and tortured at Damphu Junior High School in Chirang, which was converted into a detention center. They looked dirty, weary, weak, and extremely scared. They told me that they were beaten on their backs and soles of feet with sticks, that they had no access to toilets and safe water, and their food was contaminated with inedible particles. I saw many prominent citizens of Chirang totally broken down and humiliated. I admitted and treated number of critically ill political prisoners from Chamgang prison in Thimphu, when I worked in the infectious disease ward as physician- in-charge at Thimphu General Hospital just before I fled Bhutan, with my wife and two daughters (3-yearsrs and 2-months olds).
Nepali speaking citizens of Southern Bhutan started to flee from Bhutan in late 1990 and by 1991; substantial population lived as refugees in Assam, Bengal, and Nepal. When I arrived in Jhapa, Nepal in March 1992, about 8000 people lived in Maidhar refugee camp and another 3000 in Timai Refugee camp in very poor and despicable circumstances. They had just polythene sheets for their roofs and no protection against wind, rain, and cold. The water supply was unsafe for human consumption. There was no sanitation. The camps were a chaotic place with poor and insufficient food distribution and nonexistent regular health care. UNHCR had not yet begun its work. Many children, elderly, and pregnant women died from combination of malnutrition, stress, infectious diseases, and lack of access to health care. Malaria, meningitis, and cholera took its own toll. Diarrhea, dysentery, skin, eye infection were common. Marasmus and Kwashiorkor became rampant among children.
You are a psychiatrist. How would you describe the mental and emotional health of people in the camp and after resettlement?
Our people have suffered from injustice, brutality, and loss of properties for no fault of theirs. People were forced to forfeit their citizenship, their ancestral land, and properties. They suffered the ultimate humiliation of losing their country and sense of belonging. They were hounded, looted, humiliated and hoarded in the trucks and dumped like garbage in Nepal border at Kakarvita by Indian security forces, who worked in league with Government of Bhutan. They were mostly illiterate farmers who had seen nothing but their own villages, they were preyed by all sorts of bad actors that took advantage of their naivety and simplicity and took away their meager resources and possessions.
Refugee camps were crowded, noisy places that lacked privacy, safety, and amenities of healthy living. They received basic food items like rice, lentils, oil, salt and green plantains and potatoes for vegetables year after year. They lived in stressful security environment with nutritiously compromised diet for two decades in many cases. They had no opportunity to earn extra income to supplement their basic needs as they were confined to the refugee camps. Nepali Bhutanese have always provided for themselves and have lived with dignity of hard labor. It was painful for our families to live at the mercy of others and felt that it was due to unknown bad Karma from their previous lives.
Almost two decades of unsolved problems and failures of negotiation for political solution between Bhutan and Nepal led people to become frustrated and lose faith in amicable solution. Young people started various activities, such as marches to Bhutan and Satyagraha, to seek attention from international community for permanent solution. On the other hand, mistrust and dismay prevailed towards the leaders and responsible Governments on the minds of majority of people living in the camps leading to increased mental health problems borne out of hopelessness. Most people, including the stoics, started showing signs of wearing down, not able to enjoy things they liked in the past and losing interest in everything, worrying all the time, unable to sleep well, becoming irritable and isolating and not talking to anybody. People had started to present multiple unexplained physical symptoms, some would breakdown and cry incessantly.
When the third country resettlement option was presented in the camp, people were divided in their opinions. Younger people who had grown up in the camps and had very little emotional connection to Bhutan saw new opportunities of living a dream life in developed countries opted wholeheartedly, while the older people with fond memories of life in Bhutan felt they were betraying their mother land in opting to migrate. Different political and human rights groups in the camps spun their own takes on the issue increasing disagreements, and sometimes fights. Security situation in the camp became precarious, increasing stress for everybody.
Younger people with some education had chosen to immigrate first with the hope of making some arrangements before the entire family arrived. They had to face the daunting task of supplanting themselves from a refugee camp to fast paced life in developed country where everything was unfamiliar and challenging. There was no existing community to get guidance and support from. Cultural and language barriers made it hard and not having the emotional support of the family made it harder. Difficulty finding jobs in the recession, difficulties to commute to work to the dead-end jobs with the risk of being mugged or meeting with accidents as a new driver cannot be underestimated. The family back in the camp demanded money the resettled people did not have leading to accusations and serious misunderstandings in some cases. Some of them opted to drink to drown overwhelming sense of responsibility and burden. Early spate of suicide among the people who were trying very hard to become providers may be understood in that light.
Alarming rate of suicide after resettlement is a hair rising issue.What factors are in play to make people think about ending their lives?
It is believed suicidal thoughts are triggered by[i]:
- External stressors like inability to adjust to new and challenging environments, death of a loved one, separation from loved ones, job loss, public humiliation, and serious illnesses.
- Internal conflicts , psychological impasse , cognitive distortions and binds, more clearly seen in people with borderline , histrionic and poorly compensated narcissistic personality disorders, people who use drugs chronically.
- Neurobiological dysfunctions due to serious mental health conditions like depression, bipolar disorder, schizophrenia, panic disorder, acute stress disorder and PTSD. Alcohol and substance abuse problem can affect judgment and increase impulsivity.
The following factors seem to be at play with the Bhutanese refugee community:
- A person who is going through overwhelming stressors, who lacks family and community support, who is isolated from community and friends, who does not see any solution in sight and uses alcohol and drugs to cope are at increased risk of suicide
- History of previous suicide attempt increases suicidal risk the most
- Exposure or knowledge about suicide among family, friends, and acquaintances increases risk. It is plausible our community might be suffering from the copy cat factor to at least some extent. We have to support each other and get help for those suffering so that they do not have to opt for a violent end of their precious lives.
- Emotionally dysregulated, agitated, disorganized and impulsive person may be violent to self or others
- Financial stress, physical distress from pain and suffering, family conflict and domestic violence, physical, sexual or emotional abuse may increase the risk
- Gambling, legal complications and insolvency could expose one to suicidal thoughts and acts
- Unmarried, isolated, youths with impulsive tendencies increases the risk
- In most instances when a person thinks the suffering is overwhelming, unbearable, interminable without any hope for solution the person feels taking one’s own life as the last solution
What are the findings of research done earlier? How long can individual harbor suicidal thoughts before actually completing it?
According to the Center for Disease Control (CDC)[ii], suicide is the 10th leading cause of death in the US. Over a million people commit suicide annually all over the world. 38,000 people committed suicide in USA in 2010 and it is 3rd leading cause of death among youths after accidents and homicide. Annual rate of suicide in USA is 10.4/ 100,000 population and for the Bhutanese Refugees both in the camps as well as in the US is double of that figure[iii].
Different people commit suicide in different circumstances. It may also vary accordingly whether the person had personality problems, substance abuse history, and lack of good support system or not. Certain religions and faiths may condemn the act of suicide, acting as positive protective factor. However, if a person is telling some people that he or she does not want to live and are considering ending their lives, it should be taken very very seriously. They may be in danger of hurting themselves. Seventy five percent of people who commit suicide are known to have conveyed some people prior to the act. We should talk to them and provide care and support to get professional help. When intervention is done at the appropriate time, lives can be saved and loss and suffering for the family and friends can be prevented. With therapy and medication in addition to love and care of the family, the suicidal thoughts and intent can be prevented.
What effective measures do you want to suggest in order to prevent the present trend of suicide among the resettled Bhutanese Community?
We have to address it with multipronged approach as it is a complex issue involving spiritual, emotional, social, financial, and cultural aspects.
- We have to remain vigilant in our houses, in our neighborhoods, and the community to identify people who are suffering from the following stressors: serious mental health conditions, major setbacks like losing jobs, financial distress, loss of prestige, family break ups, and/or trauma, alcohol and substance abuse, domestic violence and physical or sexual abuse. We have to take them to Emergency rooms of local hospitals and provide sufficient collateral information to the providers so that they can make appropriate decisions. Most acutely suicidal people will need hospitalization voluntarily and in some cases involuntarily to save lives. The more support and care the family and friends can provide, the better it is for the quality of care that can be provided, including discharge planning and follow up care arrangement with culturally sensitive providers in the area.
- We should ensure safety of vulnerable individuals at any cost. We should remove medications, chemicals, guns, and other potential objects that may be used as weapons to commit suicide. Somebody should monitor and stay close to the person to avoid fatal lapses. Mental diseases can be treated like any other and there is help available in all parts of USA, we must seek help.
- We all can identify people in our own families, relations, and community who are suffering from mental illness but not getting help due to stigma related to mental illnesses. Mental diseases are like any other diseases which happen to affect the functioning of brain. Let us all campaign to treat mental illness without secrecy and taboo.
- We have to avoid indulging in risky behavior like drinking and driving, drinking too much alcohol, using drugs, gambling, risky and unprotected sex and reckless driving and crossing roads without proper inspection for safety. The communities should encourage educated youth with good moral standings to become role models and guides to younger children, get people to involve in healthy activities like games, cultural activities, and other stimulating learning activities. We can seek help and guidance from other more established and culturally similar groups to organize and manage volunteer activities.
- We can organize the community to establish community centers to provide a venue for elderly to meet for get-togethers, celebrate events, and culturally appropriate senior day cares.
- We have survived famine, natural calamities, epidemics and Bhutanese government’s brutality. Let us summon our resilience and tide over the stress of adjustment and formidable barriers to live productive lives and nurture and guide our children towards stable lives. We have a bright future in front of us as equal citizens in the most powerful, rich, and accepting country of immigrants. Let us all work together to build our American dream.
[i] Shea, Shawn C. The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors. [Lexington, Ky.?]: Mental Healthes, 2011. Print.
[In an emergency, call 1-800-SUICIDE (1-800-784-2433), the national suicide hotline. For more information on depression and other mental illnesses, contact the National Institute of Mental Health (NIMH) at: 800-421-4211, www.nimh.nih.gov]