Let’s play word association. I say, ‘epidemic’. You say:
Cholera? Malaria? Bubonic plague?
‘Suicide’ probably hasn’t come to mind but that’s how Shoklo Malaria Research Unit’s (SMRU) professor of tropical maternal and child health, Rose McGready, is describing the situation in Mae La, a 30-year-standing refugee camp on the Thai-Myanmar border.
Last year, 57 cases of suicide and attempted suicide were reported here. The reasons, says McGready, are obvious: psychosocial and socioeconomic pressures and an uncertain future over which people feel they have no control. Mae La’s 40,000 inhabitants live with no citizen status, no social security and minimal basic resources. With limited access to education and meaningful employment, they must rely on aid for basic needs.
The situation is troubling for the border’s several aid organisations, which are struggling to provide prevention and intervention programmes where human and financial resources are already scant. The challenge is compounded by the fact that mental health is an area of public health little understood by the local community, and a low priority for policymakers.
The ‘big solution’, says McGready, is to talk about it. “We must generate a culture in which people feel comfortable to come forward and [talk about suicide] but currently, we are struggling to meet the target audience of young people.”
I spoke to a group of students at a migrant school in the Thai border town of Mae Sot about why they think the epidemic is sweeping the camp, and why prevention programmes are struggling to have an impact. Four of them – Karen refugees from Myanmar’s troubled southeastern Kayin state, home to the country’s largest ethnic minority and battleground of a 50-year conflict between government and resistance armies – admit to knowing one or more people who have tried to take or have taken their own life inside Mae La refugee camp.
“She only spoke with me about it after the first time she tried [to commit suicide],” explains 20-year-old Linanna about her friend. “She’d drunk pesticide. I asked her why she’d done it. She said it was because her boyfriend had another girlfriend.”
Laura, 21, another Mae La inhabitant, talked about a friend who was there one day and gone the next. “I wondered why she was not in the school dormitory – nobody mentioned any reason. Only before the funeral ceremony my mother told me that she’d committed suicide. That was it. She said nothing more. Why was nothing said in school? Where there was potential to offer help to other young people who may be suffering suicidal thoughts?”
Min Min, a Burmese man of 23, offered one reason: “As our grandfathers and mothers felt [suicide] to be shameful, so do we. Also, Burmese people are very shy. We don’t share our problems. Especially mistakes...”
San Thi Dar, a migrant from Myanmar’s capital, Yangon, took a different standpoint, telling me: “There are just so many rules and stigmas in our religion and society that lead people to commit suicide. Especially for women. We feel inferior. For example, pregnancy outside of marriage – think of the shame that our culture imposes on that.”
At the base of this complex soup of socioeconomic pressures, stigmatisation, psychosocial trauma and uncertainty, the group of students describe deep-seated cultural mores, such as shame, that make suicide prevention programmes and mental health intervention so difficult to implement among Mae La’s vulnerable population.
There is also talk of the cultural expectations put upon women, such as chastity and domesticity, and how they feel disempowered and ashamed when they don’t live up to them. Which, when combined with the hormonal changes and psychosocial pressures of pregnancy, is causing a shocking ripple effect of pre- and postnatal suicides in Mae La. Last year, suicide accounted for half of all deaths among pregnant women and new mothers.
“During pregnancy and the postnatal period, women deal with biological changes in their bodies that put them at greater risk of developing anxiety or depression,” explains Gracia Fellmeth, DPhil student at Oxford University’s Nuffield Department of Health, who has been researching perinatal mental health in Mae La since 2015. Her study reveals that 17% of perinatal women in Mae La have at one point been affected by a common mental disorder. While similar to the UK’s 15-20%, the concerning difference lies in their impact. Fellmeth cites the UK’s rate of maternal suicide at 0.80 per 100,000 maternal deliveries. Mae La’s maternal suicide rate is 20 times that, at 16.4%.
Confronted with this fact, SMRU has placed maternity at the heart of suicide prevention efforts on the border.
According to a 2009 World Health Organization literature review, post-mortems of female suicide deaths do not always include an examination of the woman’s pregnancy status, meaning that data on exactly how many female suicides are maternity-related is largely unavailable. What numbers do reveal is that in south and east Asia, suicide rates among younger women are up to 25% higher than among their male counterparts. The report claims these are largely setting-related: limited education opportunities, less access to financial resources, restricted autonomy and greater likelihood of being threatened with violence.
As for suicide during pregnancy, the review presumes its causes by comparing the reproductive choices of women in south and east Asia with those of women in the West, where the number of antenatal suicides has greatly declined in the last 50 years, “a change attributed to the increased availability of contraception, affordable and accessible services for termination of pregnancy and reduction in the stigma associated with births to unmarried women.”
These speculations and the statistics behind them (or lack thereof) are no surprise. It is in the make-up of our history as women that we are condemned to less choice, less opportunity, less freedom, and it is in matters of sex and reproduction where our voices have been most suppressed. Yet across all cultures, you cannot produce happy and healthy children, and hence a happy and healthy society, if mothers are subjected to emotional and psychological adversity without any hope of access to support. In addition, the best way for the next generation to learn to talk about their feelings is to be raised by mothers who appreciate the importance of mental health.
“Maternal mental health has widespread consequences beyond an individual depression,” argues Fellmeth. “Impact on infants includes behavioural difficulties that continue into adulthood.” This domino social effect is currently reflected in Mae La, where the question remains ever urgent: how do we prevent more suicides?
Intervention will require a non-judgemental environment in which there is no shame attached to attending mental health clinics or therapy sessions – and which does not make demands on already scarce medical resources.
There are just two SMRU antenatal clinics catering for thousands of women in the area. Women arrive at the clinics on mopeds, in the back of pick-up trucks and in long wooden boats where no one asks for visas. Beyond the fast-filling waiting room, wards are partitioned by curtains, containing the hard wooden beds and lino sheets ubiquitous across Myanmar and Thailand. Women young and old sit cross-legged on the benches, some nursing colourfully wrapped bundles, others caressing swollen bellies. The atmosphere is one of a family day out – boxes of food are opened and shared, and gossip exchanged.
I’m allowed to enter a closed-off room where 26-year-old mental health counsellor Aye Mi sits on the floor with a 19-year-old woman and her new baby. Aye Mi translates questions from the standard psychology questionnaire Fellmeth trained her to use, and the young woman answers each question at length without hesitating – not even towards the end, when she is asked, “Have you ever had suicidal thoughts?” When the session is over, the young mother walks out, smiling to herself.
“All the women who come are very open to talk,” explains Aye Mi. A migrant herself, she has been working at the clinic for three years, first as a TB counsellor before transferring to mental health last year with Fellmeth’s programme. “The work makes me feel happy, but it’s hard,” she admits, “and not perfect. I need more training and supervision to help diagnose the illnesses.”
This lack of support is a criticism I hear from other maternal mental health counsellors in the programme. 30-year-old Htay Htay, a Karen refugee, who has lived in Mae La for the last 10 years and began her career as a maternal nutritionist, provides the only maternal mental health counselling in the camp. Every day, she sees up to 12 women, each for an hour minimum.
“To give good counselling takes time and I wish I could give it to everyone. If I could train others who wanted to help, I would, but at the moment I don’t feel confident.”
The supervision and training deficit is clear. In the past, multiple organisations have offered mental health programming on the border (Mae Tao clinic, Burma Border Projects, Première Urgence – Aide Médicale Internationale) but most of these efforts have been cut significantly or discontinued, due to cultural barriers and lack of funding. As the global humanitarian purse has contracted over the past decade, clinical mental health programmes, including training, have been hard to finance (Fellmeth’s work was largely unfunded). The result is that local providers survive on low salaries and face limited opportunities for professional development.
Despite her misgivings, the benefits of Htay Htay’s work for the local community are obvious. Six months on from her initial training with Fellmeth, she has widened her remit from the 250 women who participated in Fellmeth’s study to include women in general and even their husbands, if they wish. Word is spreading that there is someone who will listen without judgement, and who will understand.
Herein lies the strength of Fellmeth’s maternal mental health programme. It is not just about providing psychological screenings and diagnosis but also access to mental healthcare for local people by local people. In this way, the communication barriers that have hindered aid organisations’ attempts to intervene can slowly be broken down. Not only is mental health intervention in Mae La and along the border encouraging ordinary people to care for others, it’s also empowering the community’s women to look after themselves under the most challenging conditions.
Furthermore, the situation presents an important lesson for the society as a whole: that the mental wellbeing of its young mothers is the most obvious indicator of the wellbeing of future generations.