World Social Psychiatry

REVIEW ARTICLE
Year
: 2022  |  Volume : 4  |  Issue : 1  |  Page : 13--23

A Scoping Review of the Venezuelan Migration in Three South American Countries: Sociocultural and Mental Health Perspectives


Renato D Alarcon1, José Ordoñez- Mancheno2, Elvia Velásquez3, Alina Uribe4, Antonio Lozano-Vargas5, Silvia Gaviria3, Miriam Lucio6,  
1 Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Rochester, MN, USA; Honorio Delgado Chair, Universidad Peruana Cayetano Heredia, Lima, Peru
2 Department of Psychiatry, School of Medicine, Universidad de Cuenca; Latino Clínica; Asociación Ecuatoriana de Psiquiatría, Medellín, Colombia
3 Department of Psychiatry, School of Medicine, Universidad de Antioquia, Medellín, Colombia
4 Department of Psychiatry, Pontificia Universidad Javeriana; Clínica de la Mujer, Bogotá, Colombia
5 Department of Psychiatry, School of Medicine, Universidad Peruana Cayetano Heredia; Anglo-American Clinic, Lima, Peru
6 Department of Psychology and Psychiatry, Universidad de Cuenca, Cuenca, Ecuador

Correspondence Address:
Prof. Renato D Alarcon
MPH - 1 Lakeside Dr. Apt. 1602, Oakland, California 94612

Abstract

Background/Objectives: Migrations are among the most complex social phenomena in the history of mankind. In Latin America, the Venezuelan migration (VM) of the last two decades has altered the emotional dynamics of the migrant themselves and the populations of host countries such as Colombia, Ecuador, and Perú. In order to point out strategies of management and prevention, this review examines the sociocultural variables at play during the process, and the main mental health problems faced by the VM protagonists in these three Andean countries. Methods: This is a narrative/scoping review of diverse and reliable information sources about the VM in the three countries. Data are grouped in two sections: sociocultural variables and specific mental health impact. Results: Findings reflect both qualitative and quantitative information about reasons to migrate, educational level, living conditions and response from host communities, as well as mental illnesses prevalence related to experiences such as victimization by discriminatory/xenophobic behaviors, criminalization, and abuses. Conclusions: The impact of the VM has been intense and multiform on both migrant and host populations, unveiling individual, collective, social/community, and government/administrative vulnerabilities. National and international agencies must propitiate collaborative research and public/mental health initiatives for a better management of general and specific aspects of the process.



How to cite this article:
Alarcon RD, Ordoñez- Mancheno J, Velásquez E, Uribe A, Lozano-Vargas A, Gaviria S, Lucio M. A Scoping Review of the Venezuelan Migration in Three South American Countries: Sociocultural and Mental Health Perspectives.World Soc Psychiatry 2022;4:13-23


How to cite this URL:
Alarcon RD, Ordoñez- Mancheno J, Velásquez E, Uribe A, Lozano-Vargas A, Gaviria S, Lucio M. A Scoping Review of the Venezuelan Migration in Three South American Countries: Sociocultural and Mental Health Perspectives. World Soc Psychiatry [serial online] 2022 [cited 2022 Jul 6 ];4:13-23
Available from: https://www.worldsocpsychiatry.org/text.asp?2022/4/1/13/344120


Full Text



 Introduction



Migrations have taken place from the beginning of humanity's history. The study of this complex social phenomenon requires a terminology that points out similarities and differences between three concepts: Migrant, somebody who deliberately leaves his/her habitual living area to get established in another with the expectation of better life conditions;[1] Refugee, a person that leaves his/her country of origin, practically escaping from very precarious, life-threatening socioeconomic, and/or political conditions; and Displaced, someone forced to leave to another part of or outside the country due to circumstances beyond his/her control, such as natural disasters or marked social commotions.[2]

Every migration process entails, in addition to sociodemographic and political-economic aspects, a variety of geographic, ethnological, geographic, historical, and even techno-scientific features. Nevertheless, all of them seem to converge in a psycho-emotional background mediated by powerfully stressful experiences that include motivations, expectations, reputations, encounters, locations, and difficulties in the relationship with the inhabitants of the host countries.[3],[4],[5],[6]

 Objectives and Methodological Approaches



For the purposes of this review, the term “migrant” will cover the three concepts mentioned above in the assessment of sociocultural aspects and mental health features of the two protagonist groups of the phenomenon known as Venezuelan migration (VM) in Latin América: the migrants proper and the members of the host communities in Colombia, Ecuador, and Perú countries where 60%–70% of near 7 million Venezuelan migrants presently reside. The VM is probably one of the last century's social processes of the greatest impact in the continent. A growingly unsustainable sociopolitical and economic reality since the beginning of this century led to a massive migration of Venezuelans mainly oriented to three neighboring Andean countries[1],[7],[8],[9] [Figure 1]. The history and sociodemographic characteristics of the migrant population[10] offer clear evidence of heterogeneities in social, educational, occupational, and geographic location areas. Studies like this review may assist to configure an etiopathogenic chain between the stresses of the migratory journey and the inter-community encounters, with resulting multifaceted emotional responses from all.[4],[10],[11],[12] The characteristics and the role of the inevitable “intercultural collision” that occur at the points of departure and arrival, and as part of the protagonists' emotional responses,[4],[13],[14] will also be explored, allowing formulations of management approaches beyond the clinical sphere and into sociocultural realities of crucial importance in the contexts of mental and global health.[15],[16]{Figure 1}

Considering the heterogeneous nature of the VM, the information-gathering search consisted of a systematic examination of diverse and reliable bibliographic sources (scientific articles, rules, and regulations from national and international health authorities and organizations, university-degree theses, public surveys, editorials, and selected news media analyses), focused on sociocultural variables and on the mental health impact of the migration process in both, incoming and residing populations in each of the three host countries matter of this study.

 Results: Sociocultural Aspects of the Venezuelan Migration



Reasons to migrate

In Colombia, the migrants' most frequently mentioned reasons to leave Venezuela were insufficient income, 62.9%; food scarcity, 49.9%; difficulties to find a job, 31.1%; and risk or threats to life, freedom, and integrity, 13.5%. The majority expressed their desire to remain in Colombia and 81.6% of them to bring up the relatives left behind. 22.5% planned to return to Venezuela to reunite with their families “when the situation improves,” a circumstance still immersed in an almost total uncertainty.[17]

In Ecuador, a survey performed on migrants, between April and May of 2018, revealed dramatic reasons to decide abandoning Venezuela: insecurity (72.3%), “desperation for what is going on in our country” (70.8%), hunger (63.1%), high stress levels in the day-by-day life (62.9%), uncertainty (58.8%), and lack of medicines (56.3%).[18]

In Perú, the causes adduced by the migrants did not substantially differ from those above, except perhaps because they were more serious and evident from the start at the Colombian-Venezuelan border and, above all, during their crossing of Ecuador toward the South.[19] They specifically mention “lack of money” and subsequent nutritional debacle, a status of growing insecurity due to Venezuela's political situation that makes it one of the most violent countries in the world. the government's systematic campaign to minimize the relevance of the migratory process while labeling the migrants as “traitors to the Bolivarian Revolution,” had made it extremely difficult for them to obtain much needed personal and occupational identity documents.[20]

Educational level

The survey of Venezuelan Homes in Colombia revealed 27.7% of migrants with basic/elementary education, 47.0% with secondary (high school) level, and 22.0% with advanced (technical or university-based) education. In 2019, the average education among migrants was of 8.78 years, slightly greater than the 8.48 years in similar Colombian groups.[17] 5.5% were illiterate, a level similar to that in Colombia. Eighty percent of migrant children and adolescents (between 5 and 17 years of age) attended school in 2020, 80.8% of them virtually. Twenty percent did not attend any educational institution, a number that increased to 23.1% due to the COVID-19 pandemic. The reasons for which a segment of migrant children did not study were lack of a legal permission, 28.1%; lack of vacancies, 22.1%; and “other reasons,” 49.8%. Finally, 97.5% of Venezuelans with the possibility of validating professional titles or degrees in Colombia had not done so yet.

According to data from UNICEF and other sources, in Ecuador, more than half of Venezuelan migrants (59.2%) have advanced studies; in the capital city of Quito, 61.0% of migrants possess third educational level, and 39.0%, fourth level, while 41.0% of adolescents are out of the educational system.[18],[21],[22] The data may vary in each migratory wave or on the basis of the information source; according to the Organización Internacional para las Migraciones (OIM), border monitoring in 2019 indicated that only 17.5% of Venezuelans had completed university studies, and 44%, secondary education. In 2018, it was reported that 2.37% had “no education whatsoever.”[22] In the 2020–2021 school period, out of 69,241 foreign students in school programs, 50,097 were Venezuelans.[23]

In Perú, migrants with complete secondary or high school education reach an estimate of 55.5%, 7.3% complete technical studies, and 6.2% elementary school studies. 30.7% have completed advanced education, almost two-thirds of them (61.2%) being women and 38.1% men. Twenty-one percent of those with advanced education reached university level, 8.7% technical, and 1%, magister or doctoral studies.[24]

Lodging and living conditions

Almost half (48.7%) of Venezuelan migrants in Colombia live in critical overcrowding conditions, compared with 8.6% of Colombians. This situation became even worse due to the pandemic. However, to the question of whether their family was economically better now than before migrating, 52.7% answered affirmatively, 21.0% “the same,” and 25.8% “worse.” On the other hand, for 75.0%, current homelife conditions were only “intermediate” (“regular”); 16.5% good; 6.9% bad; 0.7% very good, and 1.0%, very bad. It must be pointed out that 52.9% of the migrant families were led by women.

About health coverage, 49.4% of the migrant homes surveyed are served by the Identification System of Social Programs, a payment-free government health-care modality that plans social investments and guarantees appropriate expense assignments; 46% of the migrants have not taken any steps to obtain such benefit or did not know what it was. In the field of family/domestic finances, only 14% of the migrants had a savings account, and 73% had sent money to relatives in Venezuela at least once in the last 12 months.

In Ecuador, the Public Health Ministry had provided care to 509,258 Venezuelan citizens, by 2021; in the pandemic context, until September 4, 2021, 726 cases of COVID-19 had been detected among foreigners, out of whom 388 were Venezuelans. An online survey on the status of human rights among Venezuelan migrants in the country found that 59.0% did not have problems in finding a place to live, with a monthly average payment of US $ 182, but 28.0% pointed out that they either were not granted renting options or were presented with a very costly payment guarantee due to their nationality. Thus, the fundamental problems were discrimination by rent owners and out-of-reach rent costs.[25]

Most Venezuelan migrants in Perú live in peripheral urban zones of the larger cities. In Lima, they rent modest rooms of minimal capacity in districts far off the metropolitan zone. Furthermore, a negative trend is described about salaries to migrant Venezuelan workers when compared with other foreigners, differences even more accentuated vis-à-vis Peruvian workers.[19]

If general health is considered both factor and reflection of a community's quality of life, the fact that 91.5% of the Venezuelan population in Perú do not have any kind of health insurance is revealing.[26] The Survey of the Venezuelan Population in Perú (ENPOVE-2018) found that 11% (women almost four times more than men) carried a chronic health problem (i.e., asthma, hypertension, arthritis, diabetes, or cancer). On the other hand, approximately three-fourths of Venezuelan women in Peru were of reproductive age (15–49 years) and received assistance in sexual health programs.[24],[27]

In a study of Venezuelan children younger than five, conducted in two data collection periods (August 2018 and March 2019) by the Binational Center of Border Healthcare in Tumbes, findings of anemia, breathing difficulties, diarrhea, and chronic malnutrition oscillated between 16% and 34%.[27] According to the Office of Prevention and Control of HIV/AIDS, STDs, and Hepatitis, 75.7% of 720 immigrants who received free treatment in 2018 were residing in metropolitan Lima.[28] It is also probable that the number of Venezuelan patients in need of hemodialysis may increase due to the presence of multiple risk factors for cases of chronic kidney disease.[29] Another study about health and quality of life, conducted in 2018 on 212 Venezuelan immigrants residing in two mid-size cities North of Lima, showed an 18.4% reporting pain or discomfort whereas 68.9% experienced anxiety and/or depression.[30]

Reception, responses, and dealings with migrants

Due to the prolonged period of violence and armed conflict between the government's military forces and several guerrilla groups,[31] Colombia occupies the first place in the world regarding volumes of internal population displacements. In view of the magnitude of the VM, the government created in 2011 a Special Administrative Unit ascribed to the Ministry of Foreign Affairs.[32] On the other hand, it has promoted the development of an international network that could implement common supportive measures to face the multidimensional migratory crisis, and has coordinated responses to the humanitarian crisis with the United Nations Agency for Refugees (ACNUR) and the platform R4V.[33] In March 2021, a Protection Statute to favor the migrants' legal status was elaborated.[34]

In the December 2021 Survey of Migrants,[35] 53.6% were feeling discriminated or rejected. Almost half of the group reported, however, few experiences, 30.0%, several times and 18.1%, many times. Discriminatory behaviors take place more often in the streets (34.3%) or during job searching situations (28.6%), and less frequently in actual workplaces, public transportation, commercial centers, or public offices.

To the question How integrated do you feel in Colombia?, 25.7% reported feeling very integrated, 15.9% poorly integrated, 9.8% neither very nor little integrated, and only 1.4%, not integrated at all. 41.3% pointed out that the COVID-19 pandemic had intensified feelings of discrimination or rejection.[35] In the search of work and social services, 84.5% responded that the most difficult task was to find a job, 75.0% to obtain legal migration documents, 67.3% to access health services, 48.8% to acquire internet and television resources, 35.8% acceptance by and registration in schools and other educational centers, and 30.7% cellular phone services. The survey also demonstrated that 51.7% of migrant families found themselves in a situation of “multidimensional poverty,” i.e., as victims of multiple deprivations.

There are reports of declared xenophobic behavior with very high levels of concomitant violence: the OIM found in 2018 that 27.0% of the surveyed migrants had been victims of more or less serious xenophobic acts.[36],[37] Contrariwise, a World Bank report mentioned empathetic, supportive, and assistance environments on the side of the host community, attitudes explained on the basis of fraternity links with the Venezuelan people, history of past Colombian migrations to Venezuela, and even family ties, as a good number of migrants are Colombians or members of binational families.[36]

About health measures, in 2018, Colombia's Ministry of Health and Social Protection emitted a series of dispositions to guarantee access to health services for pregnant women and children and, in 2019, published a resolution authorizing the use of all the urgency services by the migrant population, expenditures that would eventually be covered by the country's subsidized health insurance. In 2019, 372,835 migrants and refugees coming from Venezuela used health services in Colombia, an increment of 46.0% compared with the year before, even though gender disparities persisted.[36],[37]

Initially, Venezuelan migrants entered Ecuador without major difficulties, as established by the Constitution and officialized in 2017 with the Organic Law of Human Mobility.[38] Similarly, it was recommended to avoid the closing of borders, facilitate the acquisition of residence in the country, diminish bureaucratic blocking to asylum requests, eliminate high charges and fines to obtain residency, grant temporary permissions to facilitate the nationalization option, work on immigration and refugee policies, avoid judgmental considerations of political postures of the Venezuelan, moderate the public media discourse in order to diminish stigmatization, and improve the regional response from national and international organizations.[7],[25]

The migratory policies, however, have varied in the face of the increasing numbers of Venezuelan migrants and of changes in the social attitudes and behaviors from segments of both migrant and host populations. Emergency state declarations and increased control and alert operatives were necessary in several provinces (Carchi, El Oro, Pichincha, etc.).[23],[39] The requirements to enter the country have become more complicated and demanding due, among other reasons, to problems of public unrest and security in which Venezuelan migrants appeared to be increasingly involved. For such reasons, the Ecuadorian government decided to request formal information about the judicial past of adult migrants, disposition considered a violation of the Constitution and the Mobility Law. This made of Ecuador a “buffer state.”[39]

In view of these events, the country has tried to reinforce its institutional image and capacities by deploying greater numbers of officers at the points of entry and transit. A new Organic Law of Human Mobility[38] changed the classification basis of immigrants from type of activity to time of permanence, incorporating new categories that would permit the regularization of the status of a great majority of migrants. Visas granted between 2013 and 2018 reached 92,942, in addition to 40.0% of Venezuelans that could count with a permission for temporary or permanent residency.[39]

According to the OIM 2019 report,[22] the humanitarian assistance to Venezuelan migrants in Ecuador included the provision of clothing, hygienic tools, national and border-to-border transportation facilities, school materials, sources of psychosocial and emotional assistance, orientation and provision of information about protection and prevention of sexual traffic, capacitation of public officers on topics of gender and human rights, and education and training of the civil society on topics of protection to vulnerable people. To those who would manifest intentions to stay in the country or who were already in protected shelters, basic domestic tools were provided.[22],[40]

It is evident that the entry of Venezuelans has altered the social dynamics in Ecuador, which, in turn, has deepened some of the country's long-term problems, vgr., the sense of public insecurity caused by the increment of delinquency, now mostly attributed to Venezuelan migrants with penal antecedents.[18],[41] These prompted speeches and practices of xenophobia, discrimination, and racism addressed, in particular, against boys, girls, adolescents, and young adults.[18] Xenophobia is based on sentiments of “nationalism,” security, (un) availability of jobs, and social problems – a cultural and social collision of growing magnitude.[18] Hatred becomes more evident as the victims are assigned a symbolic status that transmits not only the message that they are not welcome but also the intention to hurt them.[42]

Such is the context that propitiates a disproportionate rejection, social mobilizations and petitions of expulsion of “the foreigners,” protests against the immigration, or demands of “jobs first for the Ecuadorians,” all in the name of “national security.”[40] Not surprisingly, Venezuelan migrants in Ecuador are, on many occasions, victims of criminal acts. In the case of children and adolescents, their access to schools is blocked by deliberately exaggerated administrative demands, social exploitation (forced begging), or sexual abuse.[15] These discriminatory practices in several sectors of the host society are reinforced by factors at two levels: institutional (lack of documentation that would allow appropriate census and provision of legitimate rights) and social (rejection or exploitation of Venezuelan migrants tacitly permitted by the overall host society).[18]

In surveys sponsored by entities such as UNICEF, a variety of negative emotional statements have been made, i.e., “Venezuelans are spoiled, they believe they are rich and better than us Ecuadorians” and “Venezuelans are criminals and delinquents, the women are prostitutes and they all bring up diseases.” There are also, however, some positive messages: “Venezuelans come to Ecuador pushed by necessity, it is necessary to empathize with them” and “Ecuador and Venezuela share a common history, they are brother countries.”[18]

Several surveys, conducted in Lima and other locations in Peru by NGOs, universities, and public institutions, also suggest an ambivalent reception to Venezuelan migrants by most of the host population.[43],[44] In one of them, conducted by the Institute of Public Opinion of the Catholic University of Peru in 2019, 51.0% pointed out that the habits and customs, the ways of life of Peruvians and Venezuelans, are “quite different,” and 89.0% said that Venezuelans residing in Peru must learn more about Peruvian culture, customs, habits, and traditions. Eighty-one percent agreed that many Venezuelans were devoting their time to criminal activities, thus confirming the suspicion of 61%–68.0% that considered most of them “unreliable or dishonest persons,” and the reaction of 52.0% that expressed “being much or very much afraid” of Venezuelans.[39]

This negative and discriminatory image is supported by 38.0% to 49.0% of those surveyed in the streets, transport means and public institutions, groups of friends and relatives, communication media, and social networks.[44] In the same context, 77.0% opined that the arrival of so many Venezuelans hurts the Peruvians' economy depriving them of employment positions. Such is the reason why 55.0% think that the government must apply strict limits to the number of Venezuelans that request entering the country.

Yet, the ambivalence of the Peruvian population toward the VM is reflected in the 58.0% that said to be much in agreement with the perception of migrants as “very agreeable persons,” and 52.0% who think that the majority are “hardworking and very determined” persons. 45.0% confirm the fact that a considerable number of Venezuelan migrants in Peru have received a good education in their native country.[43],[44],[45]

About the health care to Venezuelan migrants in Peru, the major obstacle to an appropriate and well-organized access is legal in nature, i.e., the lack of a formal migratory status. In order to benefit from the country's Integral Health System (SIS), immigrants must have a permit of regular or, at least, temporary residence, and must also be included in a national social registry called System of Home Focalization. Yet, even meeting such requirements, many of those who have requested asylum or have a temporal residency permit cannot access SIS, except pregnant women and children 5 years or younger. This excludes about 600,000 asylum petitioners of and migrants without legal status. In a sample study, only 32.0% of the migrants had an ID card, and only 11.0%, medical insurance coverage.[46]

Financial problems were identified in a June 2020 study, showing that 87.0% of the migrants did not have a formal labor contract. This lack of social protection is an obvious significant disadvantage when health problems supervene and disclose the ambiguity or incoherence of the requisites for access to and care in public services, and the prohibitive costs in clinics or private health establishments. The most frequently used ways to seek or receive services or assistance are, then, donations, anticipated salary payment, loans from relatives or friends, or petitions through social media, in addition to alternative forms of care such as consultations with pharmacists, nurses, other health professionals, informal telemedicine modalities, or practitioners of traditional/folkloric or magic-religious medicine.[46]

A qualitative investigation study that lasted 12 months and included 72 interviews, five focal groups, and a survey of 116 participants in five Peruvian cities explored how Venezuelans experience and make sense of the discrimination and criminalization of their nationality in their day-to-day life.[47],[48] Two-thirds of the migrants reported discrimination experiences mostly in streets or public places, and even in health establishments. These discriminatory actions go from “bad looks,” blocking provision of public and private services (i.e., taxi drivers refusing migrants as passengers), and verbal and physical aggressions.[48] On the other hand, different modalities of abuse (sexual, job- or school-related, or through social media) were reported by varying percentages (17.8%–77%) of Venezuelan women, mainly adolescents between 12 and 17 years (1 out of every 5). In turn, 2.9% reported to know victims of sexual violence.[26],[27],[48]

Additional forms of discrimination by other members of the host population include those from physicians who refuse to accept or, in fact, do not know how to use migration documents, identify a migratory status, or who can/cannot access the services. These discriminatory actions seem to be more evident in large hospitals and in health centers outside Lima.[46]

[Table 1] summarizes the main findings of the above section.{Table 1}

 Mental Health in the Context of the Venezuelan Migration



An acerbic chain of stressful factors triggered along the migratory journey from Venezuela to other countries causes mental health problems of diverse degrees of severity and consequences.[49],[50] According to the Inter-American Development Bank, the VM has generated an overwhelming emotional load to the people involved even before the arrival of COVID-19.[51] Colombia, Ecuador, and Peru had been facing increasing levels of poverty, unemployment, inequities, corruption, and subsequent political problems before the arrival of the immigrants. On the other hand, these Andean countries had historically been more original points of migrations (toward the United States, Spain, and other European countries) than receptors of large migrating groups,[51] so their migration management experience and legislation were quite limited. Paradoxically, the only Andean country with a recognized history as a receptor of migrant waves in the past was Venezuela, due to its previous condition as a prime world producer and exporter of petroleum.

There is clear evidence of an increment in the occurrence and diagnosis of defined clinical entities, other mental health problems, and the subsequent utilization of mental health services by Venezuelan migrants. [Table 2] provides a concise summary of the main findings. They are much more dramatic because there is no precise information regarding the mental health of migrants before or in the initial phases of their arrival. In Colombia, for instance, an analysis of the years 2018 and 2019 shows a clear increase in the utilization of services for conditions such as anxiety (59.3% of the consulting Venezuelan population), depression (38.1%), and suicidal behaviors (2.6%). Regarding the latter, the Venezuelan migrant population is the fourth more vulnerable in Colombia, with high suicide rates (particularly in border zones) only surpassed by hospitalized psychiatric patients, jail populations, and pregnant women.[35] There are also solid data from a study that found 21.0% of Venezuelan migrants already carrying a diagnosis of posttraumatic stress disorder (PTSD).[52]{Table 2}

Another study in 13 departments of Colombia found anxiety and depression as the most frequent mental health problems among migrants who, however, experienced significant additional stressors undermining their individual and family-based well-being, autonomy, and social development.[53] An investigation on the psychosocial factors that affect the emotional state of adolescent Venezuelan migrants suggests that the identified psychological anomalies are not similar in all the probands, as they rather depend on personal histories, cultural/educational level, personality type, factors that led to the migration, their personal perception of the process, and level of sociocultural adaptability.[54]

Colombia has a payment-free insurance system for Venezuelan migrants; in cases of compromised mental health, this insurance covers up to 10 sessions of psychological evaluation and management, references to psychiatry, and availability of medications.[52] On the other hand, there are different inter- and nongovernmental agencies that facilitate or provide psychosocial and medical support. Colombian municipalities have established a Direct Line to offer and/or connect affected people with appropriate mental health services. University-based, religious, and social institutions offer telehealth and psychological services to communities that have no access to the public health system.[40],[53],[54],[55]

It is estimated that no less than 15% of Venezuelan migrants in Ecuador suffer from a variety of medical conditions. In addition to physical illnesses such as hypertension, diabetes, and infectious diseases, the mental health of this population is seriously compromised by situations of xenophobia and discrimination that in Ecuador, as in other countries, induce mental health sequelae such as depression, anxiety or PTSD, and exacerbation of gender violence.[18],[28] As well, anxiety and depression were more frequent in migrants with university degrees compared with high school graduates.[18] Beyond the diagnosis of defined entities, the migratory experience of Venezuelans in Ecuador has affected spheres of well-being, identity, possession, and exercise of human rights.

In Peru, Carroll et al.'s study[50] conducted in April 2019 at the Binational Center of Border Care in the city of Tumbes (northern limit with Ecuador) evaluated a sample of 799 Venezuelan migrants between 18 and 70 years of age (average, 30), 49.0% of them women. Nineteen percent of the sample qualified for a depressive disorder with a score of 10 or more in the PHQ-9 Scale, whereas 23.0% showed evidence of generalized anxiety disorder with a score of 10 or more in the GAD-7 Scale, both much higher than the world prevalence levels. The study revealed important links between factors of the migratory traveling and the main clinical findings. The variable associated with a greater risk of anxiety and depression was the choice of the host country, based on hopes of security and respect at the time of arrival. Similarly, being pregnant contributed significantly to depression among migrant women, while making the journey mostly by walking led to anxiety among both, men and women. The shorter duration of the trip to Colombia protected women from depression, whereas anxiety seemed to be less severe among those who chose Peru or Chile as the fate country. The inherent risk of a totally unfolded clinical condition at the time of entering the fate country has, obviously, a well-defined prognostic value.

Xenophobia was the dominant form of discrimination experienced by 71.0% of the migrants, 77.0% of women and 61.0% of men. In focused individual and group interviews, the prevalence was even greater: 85.0% in women and 68.0% in men.[48] Rates of xenophobic discrimination varied also according to the age of the participants: 78.0% of them, younger than 35, confirmed having suffered nationality-based discrimination, compared to 63.0% among those older than 35 years.[48]

In workplaces, migrants reported having been verbally attacked by colleagues and supervisors, with statements like “Venezuelans are poor and replaceable,” reflected in lower salaries or inferior labor conditions when compared with Peruvians in similar positions. Almost two-thirds of the participants reported discrimination when presenting their CV or during job interviews. According to the qualitative survey done by the National Institute of Statistics and Informatics (INEI), Venezuelans employed in the services sector conveyed higher levels of nationality-based discrimination (80.0%) in comparison with 68.0% in the education or health sectors.[24] Other forms of discrimination include Peruvians refusing to be taken care of by “foreigners” in health centers. Besides, 18.0% of fathers (or parental figures) noticed that their children were subject of discrimination in the school, both by their peers and the teachers; at the same time, they themselves (the parents) felt excluded by the Peruvian parents.[24],[40]

From an even more serious perspective, nationality-based criminalization was experienced by 33.0% of women and 24.0% of men, accused of criminal behavior practically only because they were Venezuelans.[24] Compared to the xenophobic discrimination, the criminalization of nationality (Peruvians baselessly calling Venezuelans, “robbers” or “assassins”) singles out men slightly higher than women: 43.0 vs. 40.0%. The figures are reversed at workplaces, where 43.0% of women and 24.0% of men report being victims of criminalization. This occurs less frequently, however, to migrants that have obtained an employment better adjusted to their educational or professional training in Venezuela.[48]

With respect to the geographic ambit, both xenophobic discrimination and criminalization by nationality were more prominent in the capital city, Lima, and significantly higher in coastal cities when compared with others located near or within the Andean region.[48]

The survey from INEI in 3611 homes and 9487 Venezuelan immigrants older than 14[24] studied a representative sample from six regions (Tumbes, La Libertad, Arequipa, Cusco, Lima, and Callao). 6.3% reported mental health problems related to fear, anger, anxiety, or stress. Logistic regression analyses showed that Venezuelans that perceive themselves as discriminated had 2.4 higher probabilities of experiencing mental health problems. Using the propensity pairing score model, it was found that this group increased in 3.5 percentual points its probability to experience well-defined emotional problems when compared with homologous groups without such self-perception.

 Discussion



Every migration implies a series of individual and group processes that test the convictions, decision-making capabilities, temperamental traits, and moral principles of the participants.[56],[57] Different aspects of the process constitute significant stressors for the migrant population. The deterioration of Venezuela's political situation in the last decades has induced a massive voluntary migration, unprecedented in the history of Latin America. The mental health of the migrants, particularly of those most vulnerable and with limited resources, was put to a test across the rudest routes and most adverse situations.[10] Family distancing, the loss of home, social/cultural barriers and changes, economic difficulties, scarcity of jobs (and the concomitant underemployment in spite of professional titles or degrees), expulsions from provisional living arrangements, and lack of supportive networks are stressful experiences that, although manageable in some cases, overcome the migrants' adaptive capacities in many others, creating significant mental health risk factors.[52],[53],[54]

There is more. The border-crossing process, shaped by ambiguous and/or complex rules, aggressive attitudes, distrust, or indifference, plus uncertain and confusing administrative norms during the entry steps, characterized the first experiences in the new territory. The search of a country, a region, a city, or a neighborhood where to establish residency prolonged the resulting stress. Moreover, finally, the confrontations with a new environment (aimed at reaching a quotidian lifestyle level) configured a series of additional challenges, not the least of which was the attitude of health professionals and establishments when it – health – was compromised.[7],[15],[58],[59],[60]

The impact of the VM on the mental health of its members consistently shows five entities as those of most frequent occurrence: anxiety, depression, suicide (and suicidal behaviors), PTSD, and alcohol and drug abuse. What the sources examined in this study do not explore in detail are two important potentially pathogenic factors: the process of acculturation (present even between countries with historical, geographic, and cultural similarities)[56],[57],[58],[59] and the denial of painful experiences, aimed at avoiding labels such as “weakness” or “cowardice.” Translated into resistance to visit a health center or to talk with social assistance personnel, these behaviors entail a persistent, hidden, latent, prolonged, and – what is worse – difficult to manage emotional state. Chronicity, then, becomes inevitable.[60],[61]

In addition, the bureaucratic demands, attempted or real attitudes of abuse and discrimination, household, nutrition and health service deficiencies, evident xenophobic behaviors from the host communities, hygiene problems, and the almost generalized poverty level among the immigrants lead to the unquestionable conclusion of a seriously threatened mental health. Furthermore, Venezuelan migrants arrive with basic and mental needs unmet in their country.[51],[57] The multiple problems derived from the COVID-19 pandemic since early 2020 only worsen the risks of a massive emotional collapse inside the migrant community.[61],[62]

The stress generated by this complex process of tensions and uncertainties increases the probability of other emotions and feelings evidenced in daily life with anger and frustration that, almost inevitably, can lead to acts of violence, aggressions against themselves or others, or in the form of frankly delinquent behaviors.[1],[31],[63]

From a strictly clinical point of view, the response can range from premorbid, latent stages up to declared psychotic features such as schizophrenia. In addition, Venezuela occupies the second place in incidence of suicidal events among the Western hemisphere countries.[51],[52],[64] In the premigration period, these stress varieties can constitute traumatic events depending on the personality characteristics of the migrant; in the period of transit and due to the sensation of loss, prolonged grief, and possible posttraumatic stress; and in the post-migration, the several times mentioned cultural collision.[18],[40],[65],[66]

The adaptation process to each host country (acculturation) is a topic in need of intense multidisciplinary studies.[12],[56],[57],[59],[67] Even though language, family structure, and religion are common and vigorous cultural elements in Colombia, Ecuador, and Peru,[16],[61] it is obvious that a sufficient number of differences make out of the encounter between migrants and residents of the host country, a powerful mutual and, at the same time, unique experience.

Cultural changes can also produce profound changes in personal, individual identities resulting in more traumatic and deteriorating experiences. This review demonstrates, however, the spectrum of sociocultural variables (from family traditions to the facing of new realities in the host country) that, somehow, shape up such changes in the inner-cultural frame of each migrant. From the psychoanalytical/Lacanian viewpoint, to consider migration as an exclusively traumatic experience limits the insight that each person can formulate about the configuration of his/her identity.[68],[69],[70] It is, therefore, clear that, as has been pointed about several times, not all the effects of the migratory process will necessarily be pathogenic – they can also constitute sources of positive changes or transformations.[71]

 Conclusions



The impact of the VM in both the migrant population and the host communities has been intense and multiform. It has tested personal, familiar, and group strategies of tolerance, adaptation and resilience, possibilities of acceptance and empathy vs. potential responses of rejection or discrimination, as well as national systems of medical assistance, health care, and social coexistence. The most dramatic scenario of this process is its impact on the mental health of the migrant population, particularly its more vulnerable segments. To well-defined pictures such as anxiety, depression, or PTSD, multiple emotional, cognitive, and sociocultural features can be added, all of them predisposing to or actual threats of severe psychopathologies. National governments and international agencies must support collaborative research on diverse epidemiological, economic/financial, psychosocial, cultural, and clinical aspects of the VM but, fundamentally, on better forms of preventive-promotional management of general and specific components of the process.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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