Introduction
The world’s population over age 60 years, estimated to be 1 billion in the year 2020, is projected to reach 2.1 billion by 2050 (WHO, 2022; OHCHR, 2017; United Nations Department of Economic and Social Affairs, Population Division, 2020). Of these, 20% are estimated to have a mental health condition and 60% reside in low- and middle-income nations, where the challenging living conditions elevate the risk of human rights violations, persisting even in stable periods (WHO, 2023). A humanitarian crise is a single event or a series of events that are threatening to the health, safety, or well-being of a community or group of individuals and require action that is usually urgent and often nonroutine (Global Alzheimer’s and Dementia Action Alliance, Alzheimer’s Disease International, Alzheimer’s Pakistan, 2019). Despite the increased risks older persons face during humanitarian crises, they often are less visible in assessment and planning processes and receive less attention than younger persons and, therefore, are excluded from aid programs. The lack of inclusion of older persons in a humanitarian response and related policies is a clear violation of their human rights.
A humanitarian response includes the collective actions of actors responding to the global needs, such as protection and safety, security, access to health and social services, and relocation (Global Alzheimer’s and Dementia Action Alliance, Alzheimer’s Disease International, Alzheimer’s Pakistan, 2019). Each state has the responsibility to take care of victims of emergencies occurring on its territory. Humanitarian actors must provide assistance in accordance with the principles of humanity, neutrality, impartiality, and equity. Promoting and ensuring compliance with these principles are essential elements of effective humanitarian coordination when vulnerable people such older persons with mental health conditions are involved.
This document outlines the views of two global organizations – World Psychiatric Association Section of Old Age Psychiatry (WPA-SOAP) and International Psychogeriatric Association (IPA) – on the need to protect older persons with mental health conditions and psychosocial disability during humanitarian crises. This is a contribution of both associations to the call for input made in 2023 by the Committee on the Rights of Persons with Disabilities, UN-OHCHR.
General considerations
Dimension of the problem
In 2017, there were 335 natural disasters that affected more than 95.6 million people globally (UN General Assembly. Human Rights Council, 2017; The International Disaster Database, 1988). We regret that data on man-made disasters are missing in the reports consulted. According to a recent report, 108.4 million persons were forcibly displaced worldwide at the end of 2022 (UNHCR, 2023). Seven percent of all forcibly displaced people were over the age of 60 years (UNHCR, 2023). They often face difficulties when trying to reintegrate within the host’s community and have reduced opportunities to participate in or build social networks (UN General Assembly. Human Rights Council, 2017; The International Disaster Database, 1988; International Federation of Red Cross and Red Crescent Societies, 2020). Older people constitute a minority of displaced persons because of their limited ability to relocate as a result of frailty and other psychosocial factors, facing increased vulnerability when they are forced to stay in their own home country.
WHO (Charlson et al., Reference Charlson, van Ommeren, Flaxman, Cornett, Whiteford and Saxena2019) estimates that the prevalence of mental disorders in conflict-affected settings to be 22.1%. The mean comorbidity-adjusted, age-standardized point prevalence is 13.0% for mild forms of depression, anxiety, and post-traumatic stress disorder, 4.0% for moderate forms, and 5.1% for severe disorders. No specific data concerning older persons are available.
Defining the population concerned
Information about older victims of humanitarian crisis is inadequate due to challenges in defining old age and an older person. Older persons with mental health conditions are not solely characterized by their age or their mental health condition, and persons must not automatically carry a negative valence (Peisah et al., Reference Peisah, de Mendonca Lima, Ayalon, Banerjee, de Leo, Hwang, Ikeda, Jeste, Leon, Wang, Warner and Rabheru2021). Notions of age may vary according to circumstances, conditions, culture, and other considerations and factors, which are themselves subject to change.
Specificities of the older population in humanitarian crises context
Older persons in a context of emergencies may have several vulnerabilities caused by different factors (UN General Assembly. Human Rights Council, 2017), such as:
Intrinsic factors: poor health, disability, and frailty.
Extrinsic factors: low income, low degree of literacy, the remoteness of the place of residence, risk of abuse, limited access to resources, and rescue provisions.
Systemic factors: lack of disaggregated data and failure to assess needs correctly or to monitor the effectiveness of assistance provided.
This may be explained by the heterogeneity of this group of persons and the other forms of vulnerability they may experience (such stigma, discrimination in terms of gender, race, education level, income, health status, or access to justice) that have been accumulated during a lifetime.
Older persons’ risk of human rights violations often become more pronounced during humanitarian crises, as preexisting challenges can be exacerbated by factors including (Global Alzheimer’s and Dementia Action Alliance, Alzheimer’s Disease International, Alzheimer’s Pakistan, 2019):
Discrimination in access to basic needs for survival such as food, water, sanitation, shelter, health services, protection, and livelihood support.
Denial of the right to exercise legal capacity.
Restriction of resources.
Arbitrary detention.
Abandonment or separation from family during displacement.
Abandonment in institutional settings.
General age-based discrimination in refugee and rescue settings.
Imposition of choices, restricted autonomy, and secondary preference for help-seeking.
Health conditions associated with the aging process which are manageable under normal circumstances may become severe limitations during humanitarian crises. Mental health conditions may cause older persons hardship affected by the emergency living conditions, which may be reduce their autonomy and independence (Young et al., Reference Young, Ford and Ruzek1998; UNHCR, HelpAge International, 2010). In these circumstances, older persons are particularly vulnerable to violence, abuse, and exploitation (UNHCR, HelpAge International, 2010). They may experience loss of social connectedness that helps to protect their health and well-being by providing emotional and practical, informational, and appraisal support (Schwartz and Litwin, Reference Schwartz and Litwin2019; Schwartz and Shira, Reference Schwartz and Shira2019).
They may be excluded from programs to rebuild shelters as well as from financial assistance because of their older age (UN General Assembly. Human Rights Council, 2017). The specific needs and human rights issues of internally displaced older persons do not automatically vanish when a humanitarian crises ends (Cutter et al., Reference Cutter, Boruff and Shirley2003).
The generalization of older persons as a “vulnerable” as a whole group needing protection leads to reduced appreciation of their important roles and contributions in reducing harmful consequences of disasters and as a resource to help cope with adversity. Older persons play an important role within displaced communities, for example, by preserving cultural heritage, increasing social cohesion, and connection with their country of origin (UN General Assembly. Human Rights Council, 2017).
Human rights of older persons during humanitarian crises
The following is a partial list of essential and critical human rights which must be respected during any humanitarian crises:
The right to adequate housing entails accessibility, affordability, habitability, security of tenure, cultural adequacy, suitability of location, safety, and access to essential services, including healthcare (UN General Assembly. Human Rights Council, 2017). Displaced older persons must swiftly access suitable housing postcrisis and be safeguarded against discriminatory practices preventing older widows from owning or inheriting property (UN General Assembly. Human Rights Council, 2017).
The right to social security mandates that governments ensure this right for individuals or groups unable to realize it independently. Older persons may encounter various restrictions, including limited access to social support like pensions. These constraints on social supports can significantly heighten their risk of poverty, resulting in poor access to basic needs such as food and healthcare (UN General Assembly. Human Rights Council, 2017).
The right to work for older persons may often be denied due to discrimination based on both age and refugee status. Discrimination results in their exclusion from recovery efforts, with their skills going unrecognized. Additionally, they may be excluded from job rehabilitation programs, income-generating activities, or food-for-work programs (The International Disaster Database, 1988). There is a risk that older persons may need to find a place in the informal economy, where they can become victims of exploitation, face poor working conditions, or experience other abuses (UN General Assembly. Human Rights Council, 2017).
The right to food and health for older persons may encompass specific dietary needs that prove challenging to satisfy. Limited mobility can hinder access to proper nutrition, while the availability of medical care and relevant records may be constrained. Such constraints can disrupt the daily routines associated with healthcare and nourishment (UN General Assembly. Human Rights Council, 2017).
The mental health of older persons during humanitarian crises
Humanitarian crises and mental health
New mental health conditions may arise during humanitarian crises across all age groups, and preexisting conditions might alter their course, expression, and intensify, posing challenges for individuals to cope with adversity. In the case of older persons, the early stages of dementia might go unnoticed (Global Alzheimer’s and Dementia Action Alliance, Alzheimer’s Disease International, Alzheimer’s Pakistan, 2019). The disruption of social networks and support systems may lead to a limited recognition of mental health needs, especially among older individuals. There is a risk of a compromised mental health infrastructure, along with difficulties in coordinating facilities and staff providing mental health support. Funding for mental health and psychosocial support is often limited, with a tendency to prioritize younger age groups when such services are available (UN General Assembly. Human Rights Council, 2017).
Humanitarian crises present a series of challenges to mental healthcare responses, including (1) the heightened urgency to prioritize and allocate scarce resources, contingent on political will and effective governance, (2) constrained time for training healthcare providers, (3) restricted access to specialists, (4) limited availability of medications, and (5) the potential risk of disregarding deontological codes and ethical values within the healthcare profession (WHO, 2013; Murthy and Lakshminarayana, Reference Murthy and Lakshminarayana2006).
Humanitarian crises can serve as opportunities to enhance mental healthcare provision by prompting a reassessment of existing policies related to mental health during disasters. In the midst of and immediately following a humanitarian crisis, the media rightfully tends to highlight the challenges faced by survivors, including their psychological responses to the stressors they encounter (Murthy and Lakshminarayana, Reference Murthy and Lakshminarayana2006).
The mental healthcare of older persons during humanitarian crises
Limited research exists on delivering targeted mental healthcare for older persons during humanitarian crises. The World Health Organization (WHO) has proposed a framework that addresses many of the needs of this population (WHO, 2015, 2017). While the WHO provides clinical recommendations for managing 10 common mental health conditions, none of them specifically focuses on mental health in old age (WHO, 2015, 2017). Individuals living with neurocognitive disorders and their caregivers encounter unique challenges during humanitarian crises. In addition to the gradual decline in cognitive abilities and the manifestation of behavioral and psychological symptoms of dementia, these crises can contribute to caregiver burnout, limited access to institutional care, and constrained help-seeking, perpetuating the suffering of the family.
Conclusion
Older persons with mental health conditions face extreme vulnerability to the consequences of humanitarian crises. The risk of victims within this demographic is poised to rise in the coming years due to the expanding global older population and the escalating frequency of humanitarian crises (UNHCR, 2023).
Allowing older persons to be forgotten, overlooked, or left behind in a crisis is deemed unacceptable. Humanitarian emergencies constitute a human rights crisis for older persons, especially those who live with mental health conditions and psychosocial disabilities. A collective responsibility is imperative across all levels to raise awareness, promote, protect, and implement their human rights, dignity, and autonomy in such challenging conditions.
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Access
Introduction
The world’s population over age 60 years, estimated to be 1 billion in the year 2020, is projected to reach 2.1 billion by 2050 (WHO, 2022; OHCHR, 2017; United Nations Department of Economic and Social Affairs, Population Division, 2020). Of these, 20% are estimated to have a mental health condition and 60% reside in low- and middle-income nations, where the challenging living conditions elevate the risk of human rights violations, persisting even in stable periods (WHO, 2023). A humanitarian crise is a single event or a series of events that are threatening to the health, safety, or well-being of a community or group of individuals and require action that is usually urgent and often nonroutine (Global Alzheimer’s and Dementia Action Alliance, Alzheimer’s Disease International, Alzheimer’s Pakistan, 2019). Despite the increased risks older persons face during humanitarian crises, they often are less visible in assessment and planning processes and receive less attention than younger persons and, therefore, are excluded from aid programs. The lack of inclusion of older persons in a humanitarian response and related policies is a clear violation of their human rights.
A humanitarian response includes the collective actions of actors responding to the global needs, such as protection and safety, security, access to health and social services, and relocation (Global Alzheimer’s and Dementia Action Alliance, Alzheimer’s Disease International, Alzheimer’s Pakistan, 2019). Each state has the responsibility to take care of victims of emergencies occurring on its territory. Humanitarian actors must provide assistance in accordance with the principles of humanity, neutrality, impartiality, and equity. Promoting and ensuring compliance with these principles are essential elements of effective humanitarian coordination when vulnerable people such older persons with mental health conditions are involved.
This document outlines the views of two global organizations – World Psychiatric Association Section of Old Age Psychiatry (WPA-SOAP) and International Psychogeriatric Association (IPA) – on the need to protect older persons with mental health conditions and psychosocial disability during humanitarian crises. This is a contribution of both associations to the call for input made in 2023 by the Committee on the Rights of Persons with Disabilities, UN-OHCHR.
General considerations
Dimension of the problem
In 2017, there were 335 natural disasters that affected more than 95.6 million people globally (UN General Assembly. Human Rights Council, 2017; The International Disaster Database, 1988). We regret that data on man-made disasters are missing in the reports consulted. According to a recent report, 108.4 million persons were forcibly displaced worldwide at the end of 2022 (UNHCR, 2023). Seven percent of all forcibly displaced people were over the age of 60 years (UNHCR, 2023). They often face difficulties when trying to reintegrate within the host’s community and have reduced opportunities to participate in or build social networks (UN General Assembly. Human Rights Council, 2017; The International Disaster Database, 1988; International Federation of Red Cross and Red Crescent Societies, 2020). Older people constitute a minority of displaced persons because of their limited ability to relocate as a result of frailty and other psychosocial factors, facing increased vulnerability when they are forced to stay in their own home country.
WHO (Charlson et al., Reference Charlson, van Ommeren, Flaxman, Cornett, Whiteford and Saxena2019) estimates that the prevalence of mental disorders in conflict-affected settings to be 22.1%. The mean comorbidity-adjusted, age-standardized point prevalence is 13.0% for mild forms of depression, anxiety, and post-traumatic stress disorder, 4.0% for moderate forms, and 5.1% for severe disorders. No specific data concerning older persons are available.
Defining the population concerned
Information about older victims of humanitarian crisis is inadequate due to challenges in defining old age and an older person. Older persons with mental health conditions are not solely characterized by their age or their mental health condition, and persons must not automatically carry a negative valence (Peisah et al., Reference Peisah, de Mendonca Lima, Ayalon, Banerjee, de Leo, Hwang, Ikeda, Jeste, Leon, Wang, Warner and Rabheru2021). Notions of age may vary according to circumstances, conditions, culture, and other considerations and factors, which are themselves subject to change.
Specificities of the older population in humanitarian crises context
Older persons in a context of emergencies may have several vulnerabilities caused by different factors (UN General Assembly. Human Rights Council, 2017), such as:
Intrinsic factors: poor health, disability, and frailty.
Extrinsic factors: low income, low degree of literacy, the remoteness of the place of residence, risk of abuse, limited access to resources, and rescue provisions.
Systemic factors: lack of disaggregated data and failure to assess needs correctly or to monitor the effectiveness of assistance provided.
This may be explained by the heterogeneity of this group of persons and the other forms of vulnerability they may experience (such stigma, discrimination in terms of gender, race, education level, income, health status, or access to justice) that have been accumulated during a lifetime.
Older persons’ risk of human rights violations often become more pronounced during humanitarian crises, as preexisting challenges can be exacerbated by factors including (Global Alzheimer’s and Dementia Action Alliance, Alzheimer’s Disease International, Alzheimer’s Pakistan, 2019):
Discrimination in access to basic needs for survival such as food, water, sanitation, shelter, health services, protection, and livelihood support.
Denial of the right to exercise legal capacity.
Restriction of resources.
Arbitrary detention.
Abandonment or separation from family during displacement.
Abandonment in institutional settings.
General age-based discrimination in refugee and rescue settings.
Imposition of choices, restricted autonomy, and secondary preference for help-seeking.
Health conditions associated with the aging process which are manageable under normal circumstances may become severe limitations during humanitarian crises. Mental health conditions may cause older persons hardship affected by the emergency living conditions, which may be reduce their autonomy and independence (Young et al., Reference Young, Ford and Ruzek1998; UNHCR, HelpAge International, 2010). In these circumstances, older persons are particularly vulnerable to violence, abuse, and exploitation (UNHCR, HelpAge International, 2010). They may experience loss of social connectedness that helps to protect their health and well-being by providing emotional and practical, informational, and appraisal support (Schwartz and Litwin, Reference Schwartz and Litwin2019; Schwartz and Shira, Reference Schwartz and Shira2019).
They may be excluded from programs to rebuild shelters as well as from financial assistance because of their older age (UN General Assembly. Human Rights Council, 2017). The specific needs and human rights issues of internally displaced older persons do not automatically vanish when a humanitarian crises ends (Cutter et al., Reference Cutter, Boruff and Shirley2003).
The generalization of older persons as a “vulnerable” as a whole group needing protection leads to reduced appreciation of their important roles and contributions in reducing harmful consequences of disasters and as a resource to help cope with adversity. Older persons play an important role within displaced communities, for example, by preserving cultural heritage, increasing social cohesion, and connection with their country of origin (UN General Assembly. Human Rights Council, 2017).
Human rights of older persons during humanitarian crises
The following is a partial list of essential and critical human rights which must be respected during any humanitarian crises:
The right to adequate housing entails accessibility, affordability, habitability, security of tenure, cultural adequacy, suitability of location, safety, and access to essential services, including healthcare (UN General Assembly. Human Rights Council, 2017). Displaced older persons must swiftly access suitable housing postcrisis and be safeguarded against discriminatory practices preventing older widows from owning or inheriting property (UN General Assembly. Human Rights Council, 2017).
The right to social security mandates that governments ensure this right for individuals or groups unable to realize it independently. Older persons may encounter various restrictions, including limited access to social support like pensions. These constraints on social supports can significantly heighten their risk of poverty, resulting in poor access to basic needs such as food and healthcare (UN General Assembly. Human Rights Council, 2017).
The right to work for older persons may often be denied due to discrimination based on both age and refugee status. Discrimination results in their exclusion from recovery efforts, with their skills going unrecognized. Additionally, they may be excluded from job rehabilitation programs, income-generating activities, or food-for-work programs (The International Disaster Database, 1988). There is a risk that older persons may need to find a place in the informal economy, where they can become victims of exploitation, face poor working conditions, or experience other abuses (UN General Assembly. Human Rights Council, 2017).
The right to food and health for older persons may encompass specific dietary needs that prove challenging to satisfy. Limited mobility can hinder access to proper nutrition, while the availability of medical care and relevant records may be constrained. Such constraints can disrupt the daily routines associated with healthcare and nourishment (UN General Assembly. Human Rights Council, 2017).
The mental health of older persons during humanitarian crises
Humanitarian crises and mental health
New mental health conditions may arise during humanitarian crises across all age groups, and preexisting conditions might alter their course, expression, and intensify, posing challenges for individuals to cope with adversity. In the case of older persons, the early stages of dementia might go unnoticed (Global Alzheimer’s and Dementia Action Alliance, Alzheimer’s Disease International, Alzheimer’s Pakistan, 2019). The disruption of social networks and support systems may lead to a limited recognition of mental health needs, especially among older individuals. There is a risk of a compromised mental health infrastructure, along with difficulties in coordinating facilities and staff providing mental health support. Funding for mental health and psychosocial support is often limited, with a tendency to prioritize younger age groups when such services are available (UN General Assembly. Human Rights Council, 2017).
Humanitarian crises present a series of challenges to mental healthcare responses, including (1) the heightened urgency to prioritize and allocate scarce resources, contingent on political will and effective governance, (2) constrained time for training healthcare providers, (3) restricted access to specialists, (4) limited availability of medications, and (5) the potential risk of disregarding deontological codes and ethical values within the healthcare profession (WHO, 2013; Murthy and Lakshminarayana, Reference Murthy and Lakshminarayana2006).
Humanitarian crises can serve as opportunities to enhance mental healthcare provision by prompting a reassessment of existing policies related to mental health during disasters. In the midst of and immediately following a humanitarian crisis, the media rightfully tends to highlight the challenges faced by survivors, including their psychological responses to the stressors they encounter (Murthy and Lakshminarayana, Reference Murthy and Lakshminarayana2006).
The mental healthcare of older persons during humanitarian crises
Limited research exists on delivering targeted mental healthcare for older persons during humanitarian crises. The World Health Organization (WHO) has proposed a framework that addresses many of the needs of this population (WHO, 2015, 2017). While the WHO provides clinical recommendations for managing 10 common mental health conditions, none of them specifically focuses on mental health in old age (WHO, 2015, 2017). Individuals living with neurocognitive disorders and their caregivers encounter unique challenges during humanitarian crises. In addition to the gradual decline in cognitive abilities and the manifestation of behavioral and psychological symptoms of dementia, these crises can contribute to caregiver burnout, limited access to institutional care, and constrained help-seeking, perpetuating the suffering of the family.
Conclusion
Older persons with mental health conditions face extreme vulnerability to the consequences of humanitarian crises. The risk of victims within this demographic is poised to rise in the coming years due to the expanding global older population and the escalating frequency of humanitarian crises (UNHCR, 2023).
Allowing older persons to be forgotten, overlooked, or left behind in a crisis is deemed unacceptable. Humanitarian emergencies constitute a human rights crisis for older persons, especially those who live with mental health conditions and psychosocial disabilities. A collective responsibility is imperative across all levels to raise awareness, promote, protect, and implement their human rights, dignity, and autonomy in such challenging conditions.
Conflict of interest
Authors confirmed that they have no conflicts of interest to be declare.
Description of authors’ roles
The corresponding author prepared the draft and submitted it to the other coauthors who are IPA and/ or WPA-SOAP members for comments and review. The presidents of WPA and of the Board of IPA have given their written approval for the publication of this paper. Authors declare that they have no conflicts of interest to be declared.