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Updated: Apr 10, 2021


 

The route to successfully obtaining a comprehensive medical education, although challenging, is relatively straightforward and predictable, this involves demonstrating apt knowledge of medicine through written and practical assessments, gaining and developing clinical and social competencies by shadowing health professionals and participation in clinical and non-clinical activities. However, since early 2020 medical training for our future doctors has been severely impacted and disrupted by the COVID-19 pandemic. Most notably, the dissolution of thousands of hours of clinical training, disruption of teaching, as well as the cancellation and/ or postponement of exams (Rainbow and Dorji, 2020). In July 2020, an article published in The Lancet described how several UK teaching hospitals are

“suspending medical and observership students from attending clinical attachments”

to contain the spread of COVID-19 (Ahmed, Allaf and Elghazaly, 2021), this number has increased since. Online learning became the primary response to continue facilitating medical education during this crisis, but has it been enough?


A national cross-sectional survey conducted in 2020 looked at medical students’ perceptions of online learning. The perceived benefits of online learning according to the study included flexibility, reduction of travel costs, ease of access to lecture recordings, live lectures and teachers via the internet- students have become more self-directed learners and can digest information in their own time. Nonetheless, there are also major setbacks to online learning, the study showed that major perceived barriers included family distraction (26.7%) and poor internet connection (21.53%) (Dost et al., 2020). Another study highlighted that unemployment of family members, caring responsibilities, increased levels of stress due to long periods of self-isolation and inequality in access to remote learning platforms also disadvantaged students (Sharma and Bhaskar, 2020). Therefore, those from more vulnerable and/or underprivileged backgrounds are likely to face more environmental stressors that might impact their learning and assessment outcomes.


Under normal circumstances, medical students were already an at-risk group for increased rates of anxiety and burnout. Globally, approximately 1 in 3 medical students have anxiety, which is significantly higher than the global prevalence rate (Quek et al., 2019). A study conducted in the US showed at least half of all medical students are impacted by burnout, which is associated with suicidal ideations and psychiatric disorders (Ishak et al., 2013). More recent studies have also shown declined mental wellbeing of medical students during the pandemic, and how this has significant implications in study behaviours, and consequently their academic performance. One study highlighted students feeling emo


tionally detached from family, friends and a decrease in their overall work performance and study period (Meo et al., 2020). Another study showed that there has been a significant increase in depression, anxiety and stress during the COVID19 pandemic (Saraswathi et al., 2020). An opinion piece written by medical student Leah Komer highlights the pressures faced by medical students and the importance of appropriate support for students; explaining that

"with the demands and pressures that medical students face, it is no surprise that our mental, physical and spiritual wellbeing can be compromised. Ironically, a field that advocates the promotion of health and wellness in patients falls behind in supporting and addressing the needs of its students" (Komer, 2020)

Although all university students will face the same pressures in terms of not having face-to-face learning, medical students are unique in their struggle and are particularly more impacted by the necessary lockdown regulation and the social distancing measures. A core component of medical training is the inherent practical aspect of seeing and speaking to patients face to face, taking histories, practising and conducting different physical examinations with peers/patients and getting a real understanding of the clinical environment to gain relevant competencies.


Understandably, these skills cannot be gained traditionally during the pandemic, postponement in gaining these skills but continuous progression through the degree doesn’t solve the issue either. One study highlights the complexity of providing a medical education, and how the integration of theoretical sessions alongside clinical training and exposure is key in preparing the next generation of doctors to meet the high standards of care and professionalism: a key aspect of professionalism being clinical excellence.


Although remote learning has been a fantastic way of facilitating students to continue studying and staying in contact with peers and professors it is far from ideal, as it is unable to substitute necessary soft skills such as patient communication, professionalism and other interpersonal skills.

The COVID19 pandemic is no doubt impacting everyone in varying degrees. Social isolation, death of loved ones, unemployment and consequences of lockdown on the economy will have long term implications even after the pandemic. Medical students will also face these same implications in addition to achieving a high standard of medical training to equip them with the necessary skills to interact with the public. Therefore, universities and governments need to take appropriate measures and work with students to mitigate these consequences. This includes universities taking the initiative to promote mental health wellbeing, reaching out to students who may be struggling, improving access to counselling, financial aid, re-structuring medical curriculum and designing an effective remote learning programme to educate our future doctors even if it may take some time.


Contact the author: @silsilam

Disclaimer: the views, thoughts, and opinions expressed in the text belong solely to the author and do not necessarily reflect the official policy or position of Identity International.

 

Ahmed, H., Allaf, M. and Elghazaly, H., 2021. COVID-19 and medical education.


Dost, S., Hossain, A., Shehab, M., Abdelwahed, A. and Al-Nusair, L., 2020. Perceptions of medical students towards online teaching during the COVID-19 pandemic: a national cross-sectional survey of 2721 UK medical students. BMJ Open, 10(11), p.e042378.


Ishak, W., Nikravesh, R., Lederer, S., Perry, R., Ogunyemi, D. and Bernstein, C., 2013. Burnout in medical students: a systematic review. The Clinical Teacher, 10(4), pp.242-245.


Jodheea-Jutton, A., 2021. Reflection on the effect of COVID-19 on medical education as we hit a second wave. [online] MedEdPublish. Available at: <https://www.mededpublish.org/manuscripts/3563> [Accessed 28 March 2021].


Komer, L., 2020. COVID-19 amongst the Pandemic of Medical Student Mental Health. International Journal of Medical Students, 8(1), pp.56-57.


Meo, S., Abukhalaf, D., Alomar, A., Sattar, K. and Klonoff, D., 2020. COVID-19 Pandemic: Impact of Quarantine on Medical Students’ Mental Wellbeing and Learning Behaviors. Pakistan Journal of Medical Sciences, 36(COVID19-S4).


Quek, Tam, Tran, Zhang, Zhang, Ho and Ho, 2019. The Global Prevalence of Anxiety Among Medical Students: A Meta-Analysis. International Journal of Environmental Research and Public Health, 16(15), p.2735.


Rainbow, S. and Dorji, T., 2020. Impact of COVID-19 on medical students in the United Kingdom. Germs, 10(3), pp.240-243.


Saraswathi, I., Saikarthik, J., Senthil Kumar, K., Madhan Srinivasan, K., Ardhanaari, M. and Gunapriya, R., 2020. Impact of COVID-19 outbreak on the mental health status of undergraduate medical students in a COVID-19 treating medical college: a prospective longitudinal study. PeerJ, 8, p.e10164.


Sharma, D. and Bhaskar, S., 2020. Addressing the Covid-19 Burden on Medical Education and Training: The Role of Telemedicine and Tele-Education During and Beyond the Pandemic. Frontiers in Public Health, 8.

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Updated: Apr 9, 2021

Currently, there are more than 244 million international migrants, equating to about 3.3% of the global population (1). 75% of migration occurs within national borders, only a quarter of migrants actually cross borders to another country. Immigration is a process by which non-nationals move into a country for the purpose of settlement. While most immigration to Europe occurs legally, one of the greatest anxieties for migrants as well as an issue of huge public concern within the European Union is ‘illegal’ migrants (1).


(7)

Migration is a component of the internationalisation of the world economy as the majority of international migrations occur from low and middle income countries (LMIC) to high income countries (HIC); creating somewhat of a cultural transformation in the past century (1). A key component of this transformation is globalisation which has increased labour movements from the global south to the global north; with this, cultural identities have become even more dynamic, fluid and situationally constructed (3). But what is culture? There is no exact definition, and this haziness is how politicians can often claim legitimacy for their discourses against migration in order to preserve national ‘culture’ (3). In more recent times, culture has become a symbol for different ways of life. Evoking cultural relativism; that no culture is right or wrong, emphasising diversity as a strength is supposedly predominant in the more cosmopolitan global north/Europe which hosts a large diversity of immigrants; more than 13 million immigrants that live in the European Union come from LMIC (4).


The last two years have seen the rise of a global pandemic of ill-predicted proportions, where migrants were among those hit first and the hardest- dealing with the largest challenges in accessing health services.

The pandemic is contributing to the invisibility of migrants, an already invisible population in mainstream narrative.

Since 2020, search and rescue operations in the Mediterranean have been suspended, many sub-saharan africans who migrate through Libya were stuck there in inhumane conditions due to land and air closures- forcing them to take more dangerous routes to their intended destinations. Abusive employers and their families have been spending more time at home with live-in domestic workers. Live-in domestic workers in Gulf countries especially, are exposed to the worst conditions.


Source: http://www.ighgc.org/news-and-updates/recording-of-are-we-moving-backwards-the-multiple-jeopardy-of-gender-based-violence-migration-and-covid-19


Many governments have used the pandemic to push anti-immigration and anti-reproductive agendas. Sexual violence is commonly perceived as collateral damage of migration and is most often, not addressed in policies. Sexual and gender-based violence (SGBV) policies in transit countries for migrants are next to non-existent and migration professionals are mostly not skilled to discuss SGBV. Male migrants are often perceived as sexual predators and are not allowed to be victims in the legal or social sense. To make things worse. legal status hampers access to sexual violence services, further ignoring victimisations of all migrants and exacerbating the systemic injustices, structural and legal determinants of health inequities in migrant populations (5-7). Often, the money for humanitarian interventions are going to governments or large NGO’s that are far removed from migrant experiences and the intersection of othering that occurs leads to an accumulation of trauma that is left untreated. We need to take it more seriously.


There have been numerous ominous reports about suicides, hunger strikes and increased transmission of COVID-19 resulting from the inhumane conditions asylum seekers are having to endure in the UK Napier Barracks (former military barracks in Kent) (8). Napier Barracks has 16 blocks to house 400 asylum seekers (120 of which have confirmed COVID-19 cases). Three of these have separate private rooms but the 13 others are housing around 28 people each (9). A harrowing account from an asylum seeker stuck at the facilities still, can be found here.(10). As recent as January this year, the residents protested against these oppressive conditions with the support of a number of charity and campaigning organisations, but to no avail. Furthermore, this isn't just a UK problem- the consistent physical, psychological and medical abuse towards people detained in the US Immigration and Customs Enforcement (ICE) facilities has also created a huge COVID-19 vulnerability crisis. 16,037 people were held in ICE Detention Centres in January 2021. (11)

“ICE practices did not comply with CDC COVID-19 prevention guidance... creating unacceptable health risks which violate the constitutional and human rights of detainees”

Nearly all of the migrants interviewed by the researchers at Physicians for Human Rights (11) were unable to maintain social distancing in the conditions they were kept in. Many didn’t even have access to basic hygiene and sanitation amenities (soaps, hand sanitisers, disinfectants). Out of the 21 people who suffered from COVID-like symptoms, only 3 were isolated and tested. It is clear that migrants are seen as a burden on social/health systems and carriers of diseases that take advantage of social rights in destination countries, although these views aren't backed by research (12). At the same time, they are seen as vital to economic development, as resources to exploit without any agency.


Ultimately, more needs to be done to advance the rights and reduce the morbidities of migrant populations, especially in global crises' like the one we have all been struggling through for the past year. The lockdowns of 2020 exacerbated existing population inequalities on national and international levels and most times, migrants were excluded from this discourse.

"Those people who do not belong (yet or not anymore) to the state are neglected and utilised to foster one’s own state and threaten the states of others." (13)

Contact the author: @ludic.n

Disclaimer: the views, thoughts, and opinions expressed in the text belong solely to the author and do not necessarily reflect the official policy or position of Identity International.

 

1. McAuliffe, M. & Ruhs, M., 2018. World Migration Report 2018, Geneva. Available at: www.iom.int


2. Zimmerman, C., Kiss, L. & Hossain, M., 2011. Migration and Health: A Framework for 21st Century Policy-Making. PLoS Medicine, 8(5).


3. Wright, S., 1998. The Politicization of “Culture.” Anthropology Today, 14(1), p.7. Available at: http://www.jstor.org/stable/2783092?origin=crossref [Accessed February 9, 2018].


4. Lopez-Vélez, R.L., Huerga, H. & Turrientes, M.C., 2003. Infectious Diseases in Immigrants from the perspective of a Tropical Medicine Referral Unit. The American Journal of Tropical Medicine and Hygiene.


5. Haj-Younes J, Strømme EM, Igland J, Kumar B, Abildsnes E, Hasha W, Diaz E. Changes in self-rated health and quality of life among Syrian refugees migrating to Norway: a prospective longitudinal study. Int J Equity Health. 2020 Oct 27;19(1):188. doi: 10.1186/s12939-020-01300-6. PMID: 33109202; PMCID: PMC7590794.


6. Sacchetti E, Garozzo A, Mussoni C, Liotta D, Novelli G, Tamussi E, Deste G, Vita A. Post-traumatic stress disorder and subthreshold post-traumatic stress disorder in recent male asylum seekers: An expected but overlooked "European" epidemic. Stress Health. 2020 Feb;36(1):37-50. doi: 10.1002/smi.2910. Epub 2019 Dec 21. PMID: 31769207.


7. Sturrock S, Williams E, Greenough A. Antenatal and perinatal outcomes of refugees in high income countries. J Perinat Med. 2020 Sep 1;49(1):80-93. doi: 10.1515/jpm-2020-0389. PMID: 32877366.


8. Grierson, J. Home Office accused of cover up at camp for asylum seekers. The Guardian. 2020 Nov 23. Available from here


9. Williams, S. Asylum seekers at Napier Barracks share open letter to all British Citizens. Kent Online. 2021 Jan 21. Available from here


10. Folkestone’s Napier Barracks asylum seekers stage protest. BBC. 2021 Jan 12. Available from here


11. Physicians for Human Rights. Praying for Hand Soap and Masks: Health and human rights violations in US immigration detention during the COVID-19 Pandemic. 2021 Jan 12. Available from here


12. Visalli G, Facciolà A, Carnuccio SM, Cristiano P, D'Andrea G, Picerno I, Di Pietro A. Health conditions of migrants landed in north-eastern Sicily and perception of health risks of the resident population. Public Health. 2020 Aug;185:394-399. doi: 10.1016/j.puhe.2020.06.004. Epub 2020 Aug 3. PMID: 32758763.


13. Jauhiainen JS. Biogeopolitics of COVID-19: Asylum-Related Migrants at the European Union Borderlands. Tijdschr Econ Soc Geogr. 2020 Jul;111(3):260-274. doi: 10.1111/tesg.12448. Epub 2020 Jul 1. PMID: 32834144; PMCID: PMC7361417.


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Over the past two months or so, Identity International has been involved in a minority mental health project as part of our #BeyondStigma campaign. Through this, I've had the opportunity to have conversations regarding personal experiences as minorities suffering from mental health issues but also with experts in the field, giving their professional and personal thoughts on the matter. I'm now in the process of publishing an academic paper on this topic- you can view the pre-print here


It's no hidden fact that COVID-19 and the lockdowns of 2020 have had an enormous impact on our mental health as a global population, but as an ethnic minority- there's been the added sensationalisation of our exposure, burden and mortality from the pandemic which is disproportionate to those of white ethnic backgrounds. Understandably, this has had a toll on minority mental health in the UK, where BAME (black and ethnic minority) men were found to be suffering worse mental health outcomes compared to the rest of the UK population in 2020 (1,2). Within this, it's men of South Asian descent that are suffering the most. This was further emphasised in my conversations with both Dr Afzal and Judy who spoke about increasing mental health admissions over the lockdown periods and heightened fears from ethnic minorities about a potential genetic vulnerability to the disease.


In my paper(3), I highlighted the three key reasons why minority mental health needs more attention; discrimination, access stigma and quality of care. Below is a summary:


  • Discrimination

- Muslim populations in the UK have been known as a marginalised population from as early as 2001 and have “high concentrations in areas of multiple deprivation” (4)

- Since then, no other studies examining the spatial geographies and ethnicities of Muslims in Britain or London has been found.

- Those with stronger Muslim American identities had worse mental health consequences in the face of discrimination (5).

- Furthermore, discrimination was found to trigger PTSD symptoms directly and exacerbate PTSD symptoms related to traumatic events (6).

- This can be further compounded by racial biases, where the Care Quality Commission of 2018(7), suggested BAME groups are 4 times more likely to be involuntarily admitted to hospital for mental health issues, with Black ethnic groups at a higher risk (6).

  • Access Stigma

- In the UK, so far-there are no governmental outreach campaigns to increase awareness of mental health support within these communities.

- Muslim communities specifically, (which have been proven to be a marginalised community both religiously, ethnically, racially and socioeconomically) are disempowered in the utilisation of these services (8,9).

- More than 60% of the British orthodox Jewish community stated that they don’t feel like any mental health professional would understand their situation (10).

- There is a need for much more research in this area that also focuses on barriers for men from varying ethnic backgrounds, specifically in Black African/Caribbean communities, undocumented migrants and refugees/asylum seekers.


  • Quality of Care

- The importance of mental health professionals being trained/aware of relevant cultural and religious beliefs when dealing with patients to ensure appropriate care needs more attention.

- Cultural and religious sensitive adaptations have also been suggested for effective school-based mental health education (11).

- There is also an importance in co-producing(12) mental health therapy plans, where patients can be as involved in their treatment as the therapists, doctors, nurses etc.

- Co-producing plans helps to empower patients so they can become well- actively, not just passively. It's of growing importance in minority mental health, where more two-way communication is essential for more consensual care.


Overall, some progress has been made in understanding the complicated intersections between being a minority group in not only ethnicity, but also religiously, sexually, and neurodevelopment-ally. However, the research is still very scarce. Dr Afzal(13), mentioned in our conversation that many times mental health is pushed aside in mainstream medicine which is partly the reason why minority mental health is also neglected. Recently, more papers have been coming out about BAME mental health due to the spread of COVID-19 exacerbating existing inequalities that many minority groups were facing pre-pandemic. More needs to be done to address why a disproportionate amount of ethnic minorities are being sectioned in the UK and why they are so often misdiagnosed for years (14).


 


References

  1. John A, Pirkis J, Gunnell D, Appleby L, Morrissey J. Trends in suicide during the covid-19 pandemic. BMJ. 2020 Nov 12;371:m4352.

  2. John A, Okolie C, Eyles E, Webb RT, Schmidt L, McGuiness LA, et al. The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: a living systematic review. F1000Res. 2020 Sep 4;9:1097.

  3. Iqbal, Neelam, Minority Mental Health: Intersections between faith and ethnicity (January 16, 2021). Available at SSRN: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3767398

  4. Peach C. Muslims in the 2001 Census of England and Wales: Gender and economic disadvantage. Ethnic and Racial Studies. 2006 Jul 1;29(4):629–55.

  5. Lowe SR, Tineo P, Young MN. Perceived Discrimination and Major Depression and Generalized Anxiety Symptoms: In Muslim American College Students. J Relig Health. 2019 Aug 1;58(4):1136–45.

  6. Lowe SR, Tineo P, Bonumwezi JL, Bailey EJ. The trauma of discrimination: Posttraumatic stress in Muslim American college students. Traumatology. 2019;25(2):115–23.

  7. Mental Health Act: The rise in the use of the MHA to detain people in England. [Internet]. Care Quality Commission; 2018 [cited 2021 Jan 16]. Available from: https://www.cqc.org.uk/sites/default/files/20180123_mhadetentions_report.pdf

  8. Tanhan A, Francisco VT. Muslims and mental health concerns: A social ecological model perspective. Journal of Community Psychology. 2019;47(4):964–78.

  9. Karasz A, Gany F, Escobar J, Flores C, Prasad L, Inman A, et al. Mental Health and Stress Among South Asians. J Immigrant Minority Health. 2019 Aug 1;21(1):7–14.

  10. Kada R. Cultural adaptations of CBT for the British Jewish Orthodox community. the Cognitive Behaviour Therapist [Internet]. 2019 ed [cited 2021 Jan 16];12. Available from: https://www.cambridge.org/core/journals/the-cognitive-behaviour-therapist/article/cultural-adaptations-of-cbt-for-the-british-jewish-orthodox-community/6E04E6794651026CF5C7B323B78468F6

  11. Estrada CAM, Lomboy MFTC, Gregorio ER, Amalia E, Leynes CR, Quizon RR, et al. Religious education can contribute to adolescent mental health in school settings. International Journal of Mental Health Systems. 2019 Apr 26;13(1):28.

  12. Gault I, Pelle J, Chambers M. Co-production for service improvement: Developing a training programme for mental health professionals to enhance medication adherence in Black, Asian and Minority Ethnic Service Users. Health Expectations. 2019;22(4):813–23.

  13. Identity International (2020). #Conversationswith Dr Afzal Javed. Available at: https://www.youtube.com/watch?v=xppaMYn0CRE&list=PLKO_c9ECXwPFsScwulisWJwYF4Wb2vN3b

  14. Identity International (2021). #Conversationswith Nurse Judy Thomas: Part 1. Available at: https://www.youtube.com/watch?v=hFxbnVPQURI&list=PLKO_c9ECXwPFsScwulisWJwYF4Wb2vN3b&index=2


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