Abstract
Background
In June 2022, the European Court of Human Rights prevented a flight leaving the United Kingdom to Rwanda through an Interim Measure (N.S.K. v. The United Kingdom, 2022). Per the UK-Rwanda Migration and Economic Development Partnership, this was intended to remove migrants entering the UK by apparent illegal means. Rwanda could then grant asylum or facilitate requests to ‘safe third countries’ (BBC News, 2022a). Tellingly, affected individuals would be ineligible for UK immigration applications.
In its ruling, the European Court cautioned that asylum seekers may lack access to fair and efficient determination of their refugee status since Rwanda was not party to the European Convention on Human Rights (N.S.K. v. The United Kingdom, 2022). Praised as a human trafficking deterrent (Migration Watch, 2022), these plans have also been deemed to breach international law (CNN, 2022). Other socioeconomic debates continue (Allegretti & Rankin, 2022), and deportations remain paused due to legal challenges (Moody, 2022). Recently, despite several prime ministerial changes, the UK government reaffirmed its commitment to this scheme and rhetoric has become increasingly charged (Singh, 2022). In December 2022, the United Kingdom High Court ruled that these plans were lawful but legal appeals are expected.
From a psychiatric perspective, migrants and asylum seekers are a marginalised group, susceptible to psychopathology and distinctive risk factors. We wish to draw attention to this policy’s grave mental health consequences and emphasise social psychiatry’s relevance to ongoing discussions. At the time of writing, other European countries have proposed similar plans to remove migrants to Rwanda (Moody, 2022) and thus, these psychiatric arguments and the European Court’s ruling may become increasingly internationalised.
Mental health and the United Kingdom’s policy
Migrant mental health and vulnerable patient groups
From a patient care perspective, there are inherent concerns about this policy given the distinctive psychopathology of migrant populations. Worldwide, psychiatric issues affecting migrants are considerable and multifaceted (Bhugra, 2004). For example, individuals may exhibit sizable and persistent rates of trauma and stressor-related disorders and affective disorders (Blackmore et al., 2020), along with elevated trends in psychotic disorders (Hollander et al., 2016). Exposure to critical life events, either pre- or intra-migration, can exacerbate psychiatric and physical morbidities (Brunnet et al., 2020). Alarmingly, the United Nations contends that many English Channel crossings are undertaken by refugees (Syal, 2022), who, as research shows, are particularly high-risk for mental illness (Mesa-Vieira et al., 2022).
Forcibly relocating marginalised people to a region where they may lack sociocultural, familial, and language connections could, at the very least, heighten maladaptive coping strategies and psychological distress. Significantly, acculturation stressors have associations with psychopathology and adversely impact cultural identity (Groen et al., 2019), hindering rehabilitation and recovery (Bhugra & Becker, 2005; Nap et al., 2015).
Accordingly, it could be argued that removing individuals to Rwanda could disproportionately affect vulnerable patient groups, adding to an already complex and substantial mental health burden in migrant and refugee populations. For instance, anecdotal accounts suggest that the prospect of being deported to Rwanda has increased suicidality and self-harm for asylum seekers in the UK (Taylor, 2022).
Care deficiencies in Rwanda and sociodemographic disparities
Insufficient mental health provisions may only worsen this scenario, exacerbating human rights concerns in at-risk patient groups. In Rwanda, expertise shortages, limited evidence-based treatment, and infrastructural inadequacies endure (Kalisa et al., 2019; Rugema et al., 2015). Additionally, questions of sociocultural adaptation and long-term care entitlements for asylum seekers remain undetermined; these are absent from the UK’s proposals, as are prospective safeguarding measures for protected characteristics (Chaloner et al., 2022).
Deleterious care conditions may induce persistent psychiatric morbidities and reduced social functioning in migrants, leading to severe activity and participation limitations (World Health Organization, 2001). This is demonstrated by Australia’s asylum processing in Nauru. Although notionally temporary, asylum applicants housed in Nauru exhibited elevated suicidality, affective disorders, and trauma and stressor-related disorders (O’Connor, 2022). Moreover, whilst males predominantly undertake crossings to the UK, women and children also attempt this, albeit in smaller numbers (BBC News, 2022b). This may elicit specific issues, given female migrants are prone to gender-based risks (La Cascia et al., 2020). Equally, concerns arise about interpersonal violence, sexual assaults, and child abuse, as observed in Nauru (Farrell et al., 2016).
Human rights and legal frameworks
There has been much attention to the human rights concerns and legislative ramifications of the UK’s scheme. For example, Sen et al. (2022) rightly highlight Rwanda’s inadequate human rights record and the UK’s international legal obligations. Consequently, we believe this scheme threatens international and humanitarian commitments, like the United Nations Sustainable Development Goal (SDG) 3: Good Health and Well-being (United Nations, 2015).Whilst some have praised the policy’s deterrent effects (Migration Watch, 2022), in the authors’ view, it is morally questionable to exploit threats to the human rights of at-risk individuals and vulnerable patient groups as politicised slogans. This is especially pertinent since early data disproves the deterrence argument (Amos, 2022).
For us, it should be reemphasised that migrants often share comparable motivations; generally, they are seeking a better life, regardless of their legal status. Under this scheme, all affected individuals would be victims of double jeopardy, leaving poorer socioeconomic and healthcare conditions (or dangerous environments like conflict zones), before facing mandatory removal. Resultantly, physicians have described these plans as ‘knowingly [harming] the health of an already vulnerable population’ (Dehghan et al., 2022), which may provoke moral injuries in caregivers and destabilise the therapeutic relationship (Sen et al., 2022).
Forensic-psychiatric and medicolegal issues
The migration scheme raises medicolegal concerns since it is conceivable that the socioeconomic conditions for those forcibly relocated to Rwanda may comprise several determinants of criminality. For instance, individuals may experience deprivation, a lack of integration, and discrimination, all of which have correlations with delinquency (Schmidt et al., 2017). Again, inadequate clinical provisions for forensic psychiatry have been observed in Rwanda, including a shortage of secure in-patient facilities, scarce opportunities for education and training, and unclear legislative frameworks (Eytan et al., 2018). Should offending increase for relocated migrants in Rwanda, there is chance that some UK media outlets could sensationalise this to further justify these measures (Greenslade, 2005). If this transpires, it will substantiate holistic criticisms of this scheme as a ‘race to the bottom’ (CNN, 2022).
The role of social psychiatry
Mental health promotion and policy debates
We believe that social psychiatry can be central to shaping policy debates and raising awareness about the adverse implications of the UK’s scheme. Worryingly, other countries have mooted transporting asylum applicants elsewhere, including to Rwanda (Wienberg, 2022), which could mean that these dialogues become increasingly internationalised; wider implementation may stimulate geopolitical trends and foment a mental health crisis. Here, like so often, social psychiatry is critical in accentuating mental illness determinants and enhancing knowledge exchanges with policymakers (Ventriglio et al., 2016). To safeguard their wellbeing, it is important to highlight migrants’ structural risk factors, alongside relevant micro factors and culturally tailored approaches (Bhugra, 2004). Consequently, we contend that psychiatrists are duty-bound to warn about the psychopathological implications of such proposals, underlining migrants’ rights and needs from a mental health promotion viewpoint.
Social capital and capacity building
As the UK’s Department of Health explicates, interventions with good mental health outcomes often entail greater social capital and benefit the general population (UK Department of Health, 2011). These would be particularly applicable in the current context and may include increased access to stable living conditions (Xiao et al., 2018), integration programmes (Bhugra, 2004), cultural brokers (Sen, 2016), social support (Hashemi et al., 2021), and employment opportunities (Lai et al., 2022). Amongst others, these have improved the wellbeing and social outcomes of migrant populations.
From a mental health perspective and in line with legal argumentation, we believe that the sizable costs of transporting people to Rwanda can be better targetted. Although political realities may interfere, especially during the ‘cost of living crisis’, we call for additional investment into the future of migrant populations, instead of a flawed scheme that perpetuates their marginalisation and undermines psychiatric support. Rather than hindering humanitarian objectives, this would contribute to reductions in health disparities, advancing SDG 3: Reduced Inequalities (United Nations, 2015). Nonetheless, should flights eventually proceed removing migrants from the UK and other countries, funding for these interventions may also be integral to formulating successful care pathways in Rwanda.
Concluding remarks
The UK’s proposal to remove migrants to Rwanda raises mental health concerns, likely aggravating extant morbidities and psychological distress. Depending on its implementation, it is possible that additional countries may adopt similar policies, thus transforming this into a global issue. For us, social psychiatry has a pivotal role in demonstrating significant psychopathologies and risk factors, whilst simultaneously illustrating alternative initiatives that prioritise migrant wellbeing and human rights. Reflecting on the history of our field and previous examples of the misuse of psychiatry (Dudley et al., 2012), we believe psychiatrists have a special moral responsibility to raise awareness and advocate for vulnerable patient groups.
Presently, the words of Nobel Peace Prize winner and Holocaust survivor, Elie Wiesel, resonate increasingly loudly: ‘You who are so-called illegal aliens must know that no human being is ‘illegal’. [. . .] How can a human being be illegal?’ (Haque, 2009).
