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1.1 Background
Migration of people has been a common phenomenon since the beginning of human civilization. With increasing numbers of people moving from one country to another, migrants’ health has become a key global public health issue (WHO, 2007). There is a high chance that low-skilled migrants from low income countries work in risk prone working conditions since they usually accept the jobs that are rejected by local workers
(Weiner, 1982; WHO, 2009). Industrialized countries are interested in the recruitment of migrants from poor countries for physical labor and the migrants are often provided with short term contracts (Lowell and Kemper, 2004; Wolffers et.al, 2003). Marginalized groups such as migrants or ethnic minority groups often have inadequate access to health care services with poor provision of health services, inconvenient location of health services and cultural differences being the barriers to access to health care (Bollini and Siem, 1995; IOM, 2009; Szczepura, 2005). South Asian countries are the main suppliers of migrant workers to the Gulf countries (Weiner, 1982; Arnold and Shah, 1984; Bhattarai, 2007; UN, 2006). Nepal is one of the largest suppliers of labor to countries where there is a demand for cheap and low skilled workers. In the recent years the Gulf countries have collectively become the main destinations for international migration. An estimated three percentage of the global population move outside their country of birth, often for economic reasons (Stilwell et.al, 2004). International mobility has more than doubled over the past four decades, increasing from about 82 million in 1970 to 200 million in 2005 (GCIM, 2005). Migrants move to both developed and developing countries. Nevertheless, a majority (60%) settles in developed countries. The largest 3 single majority of migrant has settled in Europe, followed by Asia and North America; in 2000, Europe received 56.1 million migrants, Asia 49.9 million, North America 40.8 million, Africa 16.3 million, Middle East around 16.00 million (World Migration Report, 2010), Latin America 5.9 million and Australia 5.8 million migrants (GCIM, 2005).
Psychiatric disorders have long been associated with bio-psycho-social factors. The relationship of stressful events with the etiology and the course of mental illness have similarly been much considered. This study aims to evaluate the psychiatric morbidity profile of Nepalese patients with the stressors related to their work abroad.

1.2 Contributing Factors for Psychiatric Morbidity

1.2.1 Nepali workers paid less in Gulf countries

Nepali migrant workers in Gulf countries are earning half, compared to workers from other countries. They are earning less than $200 a month due to lack of skills while Filipinos, Indians and Sri Lankans are earning $300 to $350. The average earning of unskilled workers in Gulf countries — the United Arab Emirates, Saudi Arabia, Kuwait and Oman — is $217. The government’s failure to fix minimum salary for Nepali migrant
workers in other destinations has hit their earnings. Due to lack of skill trainings Nepalese are working in menial jobs in low salary. This is the greatest stress for them to cause psychiatric problem directly or indirectly.
(Himalayan News Service 2011-02-15) 

1.2.2. Exploitation and Implication to Workers

The rights of the Nepali migrant female workers in Gulf Countries have been violated, not only in the destination land, but throughout the process of migration. Depending upon an erratic male escort makes them more vulnerable since these girls/ women lack knowledge and information on safe migration. Unskilled and unaware of the situation, these women start their journey. They are completely ignorant about their destination
land's language, tradition and culture. Their only goal is to reach a foreign land, work hard and send money to their homes. Their depressions begin, once they reach a foreign land in their employers' house. Their
passports are seized and they have no access to communication. They are employed as domestic helpers, but they are physically, mentally and sexually exploited. Their work hours are limitless and they are denied rest. They have to work without complaining for more than twenty hours each day. They are not allowed to go out
of the house on their own, but only with their owners or their wife and children. To add on to their sorrows, they are often sexually exploited by the employers. Their main task is to entertain by providing good food and sexual satisfaction. They have minimal negotiation power to refrain and they have no access to any sorts of help. (Report of Maiti Nepal, Exploitation and implication on health - 2009-08-14)

1.2.3. Cheating by Employer / Recruiter

Recruiter or Manpower Companies who fix job description and salary to the workers before the employment does not only recruit them as previously fixed terms and condition but also compel them to do unexpected low grade and hardship work with minimal salary .Most of the workers who are supposed to work in international companies are forced to work in desert, as a farmer or caretaker of domestic animals like camels, sheep etc.
(Bhattarai D 2010)

1.2.4. Change in socio cultural Environment

Nepalese workers working abroad directly face change in socio culture environment. In study female workers are more influenced by this factor. Since Islam is the religion followed by majority of the population in the gulf countries, these workers are forced to give up their religion and follow Islamic rites and rituals. They are threatened to be killed and abandoned if they object. Gradually, when their physical tolerance level dwindles they start losing their mental stability. In such a situation, they are deported back to Nepal in miserable conditions. Women who arrive at the Tribhuvan Airport come penniless with a mere small handbag
or sometimes a polythene bag. Dressed in black burkha, they arrive home, penniless and fully traumatized. Few come in such despondent situations that they are bare feet and totally unaware of where and who they are. Their physical appearance and mental status at the time of their arrival is outrageously alarming.
Lack of social support can be identified as a mitigating factor for high rate of psychological disorder and mental illness found among the girls and women who have returned mainly from gulf countries. In our society, acknowledging mental and sexual health problem is a taboo. This makes it more difficult for the girls/ women to admit that they need medical intervention for psycho social or sexual problem. Consequently, women who have returned from gulf countries find it difficult to share their problems. Their families are hesitant to take them home when they find out that their ward is suffering from certain mental or physical illness. (Pro.Dr Sagroula 2011)

1.2.5. Change in climate

Nepalese people who are habituated in Nepali climate have to work in Gulf Countries at 44-52 degree centigrade temperature and also to work in desert which is sudden and unexpected change in environment for them which will be also a contributing factor for stress and long term effect of this will cause change in mental health. ( Shrestha.D, Nepali Times, ISSUE #299,26 MAY 2006 - 01 JUNE 2006)

1.2.6. Substance (LUMA) Abuse

Some Nepalese workers after hard work in construction or other laborious work in the hot climate usually consume LUMA (a solution containing high percentage of alcohol which is used as cleaner in Gulf) for pleasure and relaxation purpose due to unavailability of rectified liquor and lack of money. Long term abuse of this substance will be an aggravating factor for mental problem. This substance abuser are usually diagnosed a case of substance induced psychosis there and after returning to Nepal. (Bhattarai D 2010)

1.2.7. Suicide of colleagues

Due to hardship and low pay saps, Nepali workers committed suicide. Many Nepalese also die in traffic accidents. The dry desert climate and temperature that soars to 50 degrees inside their quarter’s means many fall sick. Due to the sudden death of colleagues many workers go to grief period which ultimately become a major stress for psychiatric morbidity. ( Ministry of Labour 2009 and Harris 2009))

1.2.8. Punishment due to Fake Documents

The Nepali embassy receives Nepalese workers cheated by employers or recruiters every day. Some haven't been paid; others have been abandoned by employers. There are now about 361 Nepalese in jail accused of having fake documents, in most cases they were cheated by fellow-Nepalese back in Kathmandu. The Nepalese workers accused and kept in jail are having severe mental problem. (Report of Maiti Nepal 2009)

1.2.9. Homesickness and Communication Gap

The workers who are working in remote and hot desert as caretaker of domestic animal have to pass months with minimum dry food and does not have accessibility to communicate with family members and even their own colleagues out there. Long terms loneliness and out of touch with reality will be one of the stress for the mental health. (Bhattarai D 2010)

1.2.10. Others

• Occupational Hazard
• Physical exertion
• Lack of balanced diet and shelter

1.3 Rationale of the Study:

The migration of Nepalese people for foreign employment began early in the nineteenth century. The perception of Nepalese migrants has radically shifted from “Global warriors to Global workers” (Graner et.al, 2003) during the last few decades. Existing poverty, limited employment opportunities, deteriorating agricultural productivity and armed conflict are some of the reasons behind international labor migration (Thieme and Wyss,2005). Most rural households in Nepal depend on the earnings of at least one family
member who is employed away from home (Gaudel, 2006 and NIDS, 2009) Nepalese migrants, especially from middle or low class families, are migrating temporarily to different countries (Gautam, 2008 and Thieme et.al, 2005). It has been estimated that in recent years more than 500 Nepalese people per day go abroad for
foreign employment (Graner and Gurung, 2003; Seddon et.al, 2002). There are an estimated 2.2 million Nepalese migrant workers, many of whom work in India, however, a large number work in the Middle Eastern oil industry (NIDS, 2008). There are several serious cases of the situation of Nepalese migrants and workers working in unauthorized countries without any legal or social protection by the host countries. Because of the different reasons (as mentioned above), Nepalese workers are suffering from Psychiatric morbidity. So, this research will be fruitful to diagnose the psychiatric problems and diseases of the Nepalese workers working abroad.

1.4 Aim:

To study the pattern of Psychiatry Morbidity among Foreign Job Returnees

1.5 Objectives:

The major objectives of the research are:
• To study the Socio-Demographic status of respondents
• To study the pattern of Psychiatric Morbidity among Foreign Job Returnees
• To find out the contributing factors leading to Mental Illness

1.6 Constraints and Limitations:

• Patients were not willing or interested to respond to queries during the survey.
• Difficulty in obtaining secondary data from Government offices regarding to Workers working abroad.

1.7 Description of the Study Area:

Tribhuvan University Teaching Hospital (TUTH) was chosen for the purpose of the study. TUTH is a tertiary based hospital located at capital of Nepal where most of the Foreign Job Returnees having health problem are brought for management by self, relatives, social workers, NGO/INGOs.

Author's Name: Dr. Deepak Giri


Author(s) : Dr. Deepak Giri