The Nepali Caste System and Culturally Competent Mental

Home , Caste system in Nepal, Ethnic groups in Bhutan, Indian Nepalis, Refugee

THE NEPALI CASTE SYSTEM AND CULTURALLY COMPETENT MENTAL

HEALTH TREATMENT: EXPLORING STRATIFICATION, STRESS, AND

INTEGRATION.

A Dissertation

Presented to

The Graduate Faculty at The University of Akron

In Partial Fulfillment

Of the Requirements for the Degree

Doctor of Philosophy

Scott Swiatek

May 2021

THE NEPALI CASTE SYSTEM AND CULTURALLY COMPETENT MENTAL

HEALTH TREATMENT: EXPLORING STRATIFICATION, STRESS, AND

INTEGRATION.

Scott Swiatek

Dissertation

Approved: Accepted:

______Advisor Department Chair Dr. Juan Xi Dr. Rebecca Erickson

______Committee Member Dean of the College Dr. Clare Stacey Dr. Mitchell S. Mckinney

______Committee Member Dean of the Graduate School Dr. Manacy Pai Dr. Marnie Saunders

______Committee Member Date Dr. Kathy Feltey

______Committee Member Dr. Marnie Watson

ABSTRACT

During the late 1990s, the Northern Bhutanese enacted policies marginalizing

Bhutanese of Nepali Descent. Thousands of Bhutanese refugees were forcibly displaced to Nepal and established refugee camps where they lived for decades. While in the camps, refugees encountered traumatic life events, including torture, imprisonment, and sexual violence. Starting in 2008 and continuing for years. Bhutanese/Nepali refugees were resettled in the Akron area and encounter a new set of acculturation stressors related to finding employment, learning English, and reestablishing a new set of social networks.

Older adults may cling to the Nepali caste system to cope with the unique stressors during the integration process. For over 100 years, people of Nepali descent subscribed to

Muluki Ain, which codified discrimination against lower castes and mandated every individual be assigned a caste. Further, members of the ethnic and religious minority were often placed in the lower castes. Although discriminatory policies have been repealed, many Bhutanese of Nepali descent still subscribe to the caste system.

This dissertation demonstrates that the caste system relates to health. On the one hand, the caste system operates as a fundamental cause, which may worsen physical and mental illness for lower castes. On the other hand, not everyone in the higher castes may experience their social position's benefits. Findings suggest that older women and persons with disabilities may encounter additional barriers to care. These findings demonstrate that Bhutanese/Nepali refugees would benefit from culturally competent programming sensitive to community member caste and religion. The community would also benefit

iii from expanding social services related to learning English, finding employment, and community gardening. However, the federal government needs to ensure that local programs receive adequate funding and repeal restrictions on refugee admission.

TABLE OF CONTENTS

Page

LIST OF FIGURES ...... xi

LIST OF TABLES ...... xii

CHAPTER

I. INTRODUCTION ...... 1

METHODS ...... 6

Neighborhood Setting ...... 6

Pilot Project ...... 8

Project Overview ...... 10

Sampling Strategies ...... 11

Coding Procedures ...... 12

Community Member Demographics ...... 13

Provider Characteristics ...... 14

OVERVIEW OF CHAPTERS ...... 15

II. HISTORY AND CULTURE ...... 17

Bhutanese Culture and Ethnic Relationships ...... 19

History of the Bhutanese Ethnic Cleansing ...... 21

Life in the Camps ...... 29

The Resettlement Process ...... 35

The Nepali Caste System ...... 39

III. CASTE AS A FUNDAMENTAL CAUSE ...... 44

LITERATURE REVIEW ...... 46

Traumatic Experiences in Bhutan ...... 46

Acculturation Stress and the Stress Process Model ...... 49

The Caste System ...... 50

Caste as a Fundamental Cause ...... 52

Cultural Health Capital ...... 54

Caste Resources and Coping ...... 55

Mental Health Consequences ...... 57

Theoretical Framework ...... 59

METHODS ...... 61

Sampling Methods and Coding Procedures...... 63

Community Member Characteristics ...... 63

Provider Characteristics ...... 64

PROVIDER RESULTS ...... 65

COMMUNITY MEMBER RESULTS ...... 70

TIKA AND PRAKESH: SEEKING TREATMENT IN NEPAL ...... 71

SARAH: ACCULTURATION STRESSORS ...... 75

BHIM: CULTURAL HEALTH CAPITAL ...... 79

DISCUSSION ...... 82

Conclusion ...... 85

IV. THE CASTE SYSTEM: BARRIERS TO INTEGRATION AND CARE ...... 87

LITERATURE REVIEW ...... 89

Assimilation, Integration, and Enclaves ...... 89

Theoretical Framework ...... 91

Economics and Barriers to Integration and Healthcare ...... 93

Social Networks as a Barrier to Integration and Healthcare ...... 96

Language and Culture as a Barrier to Integration and Healthcare ...... 97

METHODS ...... 100

Sampling Strategy and Coding Procedures ...... 100

Community Member Characteristics ...... 102

Provider characteristics ...... 102

COMMUNITY MEMBER RESULTS ...... 103

Stigma as Barrier to Integration and Healthcare ...... 103

Social Networks and Social Isolation as Barrier to Integration and Healthcare ..... 105

Employment as Barrier to Integration and Healthcare ...... 111

Language and Culture as Barrier to Integration and Healthcare ...... 114

vii

PROFESSIONAL/PROVIDER RESULTS ...... 118

Caste and Barriers to Treatment ...... 118

DISCUSSION ...... 120

Conclusion ...... 123

V. CULTURALLY COMPETENT MENTAL HEALTH TREATMENT ...... 125

LITERATURE REVIEW ...... 126

Bhutanese/Nepali Conceptualization of Mental Health ...... 126

Community Members and Stressors ...... 128

Social Support and Coping ...... 130

English as a Second Language and Coping ...... 131

Religious Beliefs and Coping ...... 132

Sampling and Coding Procedure ...... 136

Community Gardening and Coping ...... 137

METHODS ...... 140

Community Member Characteristics ...... 141

Provider Characteristics ...... 142

COMMUNITY MEMBER RESULTS ...... 142

Expanded Educational Programming ...... 143

Use of Religion to Cope ...... 145

viii

Conversion to Christianity ...... 147

Community Gardening ...... 148

PROVIDER RESULTS ...... 150

Educational Programming: ...... 150

Community Gardening ...... 151

DISCUSSION ...... 152

Conclusion ...... 155

VI. CONCLUSION...... 156

Theoretical Contributions ...... 159

Limitations of the Current Study ...... 163

Role of the Researcher and Team ...... 166

Personal Reflections: Refugee Resettlement in Crisis ...... 169

Contemporary Refugee Resettlement Policies ...... 171

Policy Recommendations ...... 173

Conclusion ...... 175

REFERENCES ...... 176

APPENDICIES ...... 193

APPENDIX A. COMMUNITY MEMBER INFORMED CONSENT FORM ...... 194

APPENDIX B. COMMUNITY MEMBER INTERVIEW GUIDE ...... 197

APPENDIX C. PROFESSIONALS/PROVIDERS INFORMED CONSENT FORM .. 200

APPENDIX D. PROFESSIONAL/PROVIDER INTERVIEW GUIDE ...... 203

LIST OF FIGURES

Page

Figure

Figure 1: Theoretical Model of Influences on Health Outcomes ...... 59

Figure 2: Theoretical Model of Barriers to Care and Integration ...... 92

LIST OF TABLES

Page

Table

Table 1: Alcohol as a Problem in the Community ...... 9

Table 2: Community Should Provide Mental Health Treatment ...... 9

Table 3: Summary Statistics ...... 14

Table 4: Provider Characteristics ...... 15

Table 5: Timeline of the Ethnic Cleansing of the Southern Bhutanese ...... 29

Table 6: Summary Statistics ...... 64

Table 7: Provider Characteristics ...... 65

Table 8: Participant Pseudonyms ...... 71

Table 9: Summary Statistics ...... 102

Table 10: Provider Characteristics ...... 103

Table 11: Summary Statistics ...... 141

Table 12: Provider Characteristics ...... 142

xii

CHAPTER I

INTRODUCTION

Since 2007, thousands of Bhutanese refugees have resettled throughout the United

States and other western nations. Southern Bhutanese of Nepali descent primarily settled in Bhutan to develop farms and received financial support from the government (Evans

2010; Hutt 2005; Rizal 2004). Before resettlement, Southern Bhutanese were expelled from their own country by the Wangchuk monarchy, who feared losing their cultural identities (Dutton 2011; Hutt 2005; Rizal 2004). The government enacted a series of discriminatory policies, which stripped Southern Bhutanese of their rights (Dutton 2011;

Evans 2010; Loescher and Milner 2005). Protests erupted throughout the country, spurring the monarchy to retaliate, leading to thousands of human rights violations.

Indeed, Southern Bhutanese were frequently imprisoned, tortured, and raped (Dutton

2011; Loescher and Milner 2005; Shrestha 2011). These actions caused nearly 100,000 refugees to flee to camps located in the Jhapa district of Nepal, and they remained in these camps for decades.

Bhutanese of Nepali descent follow the caste system. Several studies assert that the caste system functions as an ascribed status, which defines social positions (Gellner

2007; Patel 2012; Subedi 2011). For more than a century, the Nepali legal code (Muluki

Ain) permitted caste-based discrimination. Under Muluki Ain, policies were intended to

1 secure the power of the Hindu religious majority and hill tribes in Nepal (Cox 1970;

Levine 1987). People outside of the majority were assigned to the lower castes. The caste system also gave men more power over women of the same caste. However, women from the higher castes often commanded more privileges than people in the lower castes (Patel

2012). The lower castes were forced to work in the service sector and were often barred from the education system.

According to the Nepali legal system, every ethnic group falls into one of the four castes based on the Indian varnas (Cox 1970; Levine 1987; Patel 2012). Further,

Bhutanese of Nepali descent continued to follow the caste system upon initial settlement in Bhutan and resettlement into refugee camps (Patel 2012). The Shudra compose the lowest caste and work in low-status occupations (Bennett, Dahal, and Govindasamy

2008; Gellner 2007; Subedi 2011). The lower caste encountered acts of discrimination from higher castes and were marginalized by government policies. The Vaisya are the middle caste who practice a skilled trade or own a small business (Gellner 2007). The

Brahmin and Chattriya compose the highest castes who work in prestigious occupations such as government, religion, and academia (Gellner 2007; Subedi 2016b). Upper castes typically receive privileges including access to education, property, and power. Ott

(2013) has also found that the higher castes were resettled before people in the lower castes. Members of the upper castes frequently complete secondary resettlements closer to extended family members.

It has been well documented that traumatic life events have profound destructive impacts on mental health. Fundamental causes and acculturation stress are used to understand how caste status shapes the mental health outcomes of Bhutanese refugees.

Members of lower castes living in Bhutan were more likely to live in challenging conditions and work in precarious occupations (Furr 2005; Patel 2012; Subedi 2016b).

Indeed, low social position functions as risk factors that lead the lower castes to develop a range of mental health conditions. Individuals belonging to the lower castes also have access to fewer resources such as income, education, and prestige (Furr 2005; Gellner

2007; Subedi 2016b). According to Link and Phelan (1995), access to resources increasingly functions as a buffer against mental illness and increases the ability to find medical treatment. Pearlin et al. (1981) further indicate that individuals with fewer resources lack social support and other methods to cope with stressors.

As a result, members of the lower castes are more vulnerable to the negative impacts of traumatic life events. The lower castes were treated unfavorably in refugee camps and during the resettlement process (Ott 2013; Patel 2012). The caste system works as a fundamental cause of illness that impacts Bhutanese refugees during their refugee experiences and differentiates mental health outcomes. However, when

Bhutanese/Nepali refugees were resettled, new challenges awaited: adjusting and integrating into the host society. Scudder and Colson (1982) suggest that the caste system may persist because refugees are clinging to traditions to cope with new stressors in their host society.

Indeed, there is a range of health consequences associated with having membership in a lower caste. Patel (2012) indicates that people belonging to lower castes encounter discrimination and report that their mental health has been negatively impacted. A report conducted by Bennett et al. (2008) demonstrates that members of lower castes who are illiterate often do not have access to public health information to the

3 same extent as the higher castes. Members of lower castes are also less likely than members of higher castes to seek treatment for a physical or mental health condition

(Bennett et al. 2008; Patel 2012). Further, the lower castes perform worse on epidemiological measures than the higher castes (Bennett et al. 2008; Patel 2012).

Bennett et al. (2008) have found that lower castes have higher infant mortality rates and maternal mortality than higher castes.

Resettled refugees encounter several barriers associated with treatment for mental health conditions and disorders related to substance abuse. Community members who experience barriers to achieving economic integration likely lack the financial resources they need to find mental health treatment (Ager and Strang 2008; Dutton 2011). Refugees who cannot find stable employment report having a lower self-concept, which may exacerbate persisting life strains (Ao et al. 2012; Gurung 2019). Bhutanese/Nepali community members struggling to learn English have trouble navigating their host societies and seeking mental health treatment (Dutton 2011; Miller and Rasco 2004).

Inability to communicate prevents resettled refugees from utilizing public health information and seeking emergency medical treatment (Ager and Strang 2008; Bennett et al. 2008; Dutton 2011). Disruption to social networks is another barrier to integration and treatment (Ager and Strang 2008). Newly resettled refugees are often separated from their family members and friends, which damages their ability to rely on their connections to other people (Benson et al. 2012; Lundström and den Uyl 2010).

Finally, culturally competent treatment programs can be implemented to improve health inequalities in the Bhutanese community. New social service programs could better assist refugees with learning English, finding employment, and navigating their

4 communities (Hoellerer 2013; Ott 2011). Programing at local agencies could provide refugees with a safe space to discuss mental health conditions and substance use (Dutton

2011; Miller and Rasco 2004).

Resettled refugees increasingly use religion as a coping mechanism to combat stressors and use their faith as a coping mechanism (Benson et al. 2012; Hodge 2004;

Woods and Pulla 2016). Indeed, refugees report performing rituals, prayers, and meditation to help them cope with stress and life strains. Community gardens are another coping resource that refugees that provide them with the ability to preserve their culture and interact with other people. Bhutanese/Nepali refugees engaging in community gardening report a more positive self-concept and perceived social support (Hartwig and

Mason 2016; Hinton 2016).

This dissertation seeks to understand how caste status shapes the resettlement experiences of Bhutanese/Nepali refugees. Resettled Bhutanese/Nepali community members encountered a range of stressors associated with their flight from Bhutan: decades living in Nepali refugee camps and experienced human rights violations.

Refugees who have resettled in the United States experience ongoing trauma, as well as a new set of stressors associated with integration. Resettled refugees encounter barriers to integration such as finding stable employment, learning English, and maintaining social networks. Ager and Strang (2008) assert that refugees who struggle to integrate into their host society are less likely to seek treatment for mental health conditions. Membership in the lower castes may exacerbate barriers to integration and mental health treatment; the lower castes often have less access to resources than people belonging to upper castes

(Gellner 2007; Subedi 2016b). Numerous studies have found that expanding social

5 service programming, practicing religion, and developing community gardens improves coping in refugee communities (Dutton 2011; Hartwig and Mason 2016; Pumariega,

Rothe, and Pumariega 2005). Ultimately, my dissertation is guided by the central research question “How does caste status shape Bhutanese/Nepali refugees' experiences after they are resettled”?

METHODS

The data used to carry out this study consist of in-depth interviews conducted with 100 Bhutanese/Nepali community members. The data also includes interviews with

20 social services providers (e.g., mental health clinics, resettlement agencies). These data were collected as part of a Bhutanese Refugee Substance Abuse Study, a collaborative project between the University of Akron and the International Institute of

Akron (IIA). The original project aimed to identify barriers to mental health treatment and create a culturally competent substance abuse treatment program1. I participated in the original project, first through a paid internship with the IIA, followed by two semesters conducting additional provider interviews to ensure data saturation.

Neighborhood Setting

The field site for this project was Akron's North Hill neighborhood, as well as surrounding communities such as Cuyahoga Falls and Tallmadge. Interviews took place inside of community member households, resettlement agencies, local libraries, and health clinics. Local papers such as The Akron Beacon Journal and the Devil Strip

1 A manuscript based on this project has been prepared and is under review at Human Organization. Papers have also been presented at the Society for Applied Anthropology conference, the American Anthropological Association, Association for Applied and Clinical Sociology, and the North Central Sociological Association.

6 document that this neighborhood is very diverse and over thirty languages are spoken in the area, including Arabic, Vietnamese, and Nepali (Garrett 2019; Hindi 2019). Data from the American Community survey further indicate that nearly half of the North Hill neighborhood consists of racial minorities and 20 percent of residents are Asian (Hindi

2019). Journalists have also documented that the first family of Bhutanese refugees was resettled by local agencies in 2008, and approximately 5,000 Bhutanese of Nepali descent have settled throughout North Hill (Hindi 2019).

The data were collected by a research team managed by Dr. Marnie Watson, a research associate in anthropology at the University of Akron. Dr. Watson secured IRB approval, created the interview guides, conducted interviews, and managed the project.

Five research assistants from the University of Akron worked on data collection. The three graduate students working as research assistants on the project were myself, Jimmy

Carter (sociology), and Nuha Alshabani (counseling psychology). We were responsible for collecting in-depth interviews from participants, transcribing the interviews, creating a codebook, and conducting the data analysis. An undergraduate student, Julian Curet, from the Department of Anthropology at the University of Akron, also assisted with the data collection. Another undergraduate student, Vyshu Ramini, majoring in pre-medicine, assisted with transcription and coding. Our team also utilized a cultural broker, Santa

Gajmere, who the International Institute hired to work as our translator. Santa was responsible for interpreting interviews conducted in Nepali, obtaining informed consent, debriefing participants, and recruiting participants to interview.

Our research team also collaborated with the International Institute of Akron

(IIA), a nonprofit that provides programs to help new immigrants integrate into the

7 community. The study was suggested by Radha Adhikari, who was formerly in charge of social services at IIA. She reached out to the Department of Anthropology at the

University of Akron requesting a project to help community members obtain treatment for substance abuse. According to their webpage (Anon 2019), the institute offers resettlement services, education programs, employment services, and various programs for the community. Additionally, many of these services are available to immigrants who either resettled directly into the area or moved to Akron after initial earlier resettlement from another city (secondary migration). IIA's education programs help migrants learn

English, acquire American citizenship, and complete their GED. They also offer employment services, assisting immigrants with finding a job or providing job training.

IIA provides the greater Akron area with translation/interpretation services. These services also consist of onsite or over-the-phone interpretation, interpreter training, and document translation. Local businesses, hospitals, and government entities are the primary consumers of the International Institute's services.

Pilot Project

A pilot survey was developed and distributed to 200 members of the

Bhutanese/Nepali community, which was intended to gauge the prevalence of substance abuse. There were 40 cases dropped due to sampling error (N=160). Table 1 displays community members' beliefs that alcohol is a problem in the community. Seven respondents (four percent) reported that alcohol abuse is never a problem in the community. However, 147 respondents (93 percent) believed that alcohol is always a problem in the community.

Table 1: Alcohol as a Problem in the Community

100% 93%

80%

60%

40% Percent

20% 4% 1% 3% 0% Never Sometimes Often Always Perception of Indicator

*N=160

Table 2 shows that an overwhelming majority of respondents (92%) believe that the community should provide mental health treatment. Only six respondents (4 percent) said the community should never provide care. Anecdotal data from the International

Institute suggests a rise in social work cases related to alcohol abuse. The majority of respondents agreed that the community needs treat mental health conditions and substance abuse disorders.

Table 2: Community Should Provide Mental Health Treatment

100% 92%

80%

60%

40% Percent

20% 4% 1% 3% 0% Never Sometimes Often Always Perception of Indicator

*N=160

Project Overview

This dissertation contributes to the literature on fundamental causes of illness, cultural health capital, the stress process model (SPM), and integration. I seek to bridge a gap in the literature by understanding how caste status shapes the resettlement experiences of Bhutanese/Nepali refugees. In-depth interviewing is an appropriate method, as it allows the researcher to make cultural inferences based on how participants perceive their social worlds (Gubrium and Holstein 2001). I conducted fieldwork throughout the summer of 2017 during a collaborative project. This research was a partnership between the University of Akron and The International Institute of Akron

(IIA). The project's original goal was to develop a culturally competent alcohol treatment program, which could help members of the Bhutanese community find treatment for alcohol abuse, mental health, and problems substance abuse causes in the community.

The primary investigator and research assistants collected 100 in-depth interviews with the Bhutanese community resettled in the Akron area. Our respondents would all be considered first-generation immigrants, but some of the people we interviewed may have been born in refugee camps. The interviews covered a range of topics, including perceptions of the Akron area (e.g., What are some negatives about Akron?), access to social services (e.g., Have you received any services from the International Institute of

Akron?), perceptions of alcohol use (e.g., Who is drinking alcohol in the Bhutanese community?), and potential community-based solutions for mental health treatment (e.g.,

Do people in the community with alcohol problems seek help?).

An additional 20 interviews were conducted with social service providers who interacted with and provided services to the Bhutanese (e.g., employment services,

10 resettlement agencies, mental health clinics). Interviews conducted with providers focused on three domains including the participants work with the refugee community

(e.g., Please describe the work you do with the refugee community in Akron in general?), substance abuse (e.g., Do you think there is a problem with alcohol or other substance abuse in the Bhutanese refugee community?), and community-based treatment (e.g.,

What success have you seen in providing treatment for alcohol or drug abuse for people from the Bhutanese refugee community?). Both types of interviews were approximately

45 minutes long and sometimes were conducted with multiple participants. There were

66 interviews, with 39 conducted individually and 27 as a dyad or with multiple participants. Each of these interviews was recorded using an Olympus digital recorder and transcribed using Express Scribe transcription software.

Sampling Strategies

Snowball sampling was employed to reach members of the Bhutanese community. Participants were contacted by our cultural broker of Nepali descent from

IIA, who asked respondents if they would like to participate in the study. After agreeing to participate, community members completed the interview with a research team member, with the cultural broker present to translate. Snowball sampling allows researchers to study vulnerable populations or groups that are hard to reach (Sadler et al.

2010). Snowball sampling is also beneficial because it enables participants to avoid stigma from people who are not community members and enables the researchers to reach subgroups of the sample (Sadler et al. 2010). Snowball sampling allowed us to reach each of the four principal castes living in the Akron area and discuss topics that

Bhutanese/Nepali community members would be reluctant to talk about without a

11 cultural broker. Additionally, other strategies to recruit participants may not have been effective because most Bhutanese/Nepali community members did not speak English.

Our team also employed theoretical sampling, which allowed us to reach different subgroups within the sample. Prior research has found that theoretical sampling permits researchers to refine emergent categories in their study based on our interpretations of the data before returning to the field to conduct more interviews (Charmaz 2008; Corbin and

Strauss 1990; Glaser and Strauss 1967). Santa, our cultural broker, targeted respondents based on their gender, caste, age, and religion, which ensured that the Bhutanese/Nepali community's diversity was adequately represented (Charmaz 2008; Glaser and Strauss

1967). About 20 interviewees were reached using target sampling. Our team worked to ensure that we included women and Buddhists in our sample who we believed were underrepresented. The cultural broker, Santa, recorded participant demographics during the completion of the informed consent form.

Coding Procedures

Interviews were transcribed using Express Scribe transcription software. After the interviews were transcribed, they were uploaded to a password-protected server and reformatted to be coded using NVivo 12 Pro. Members of the research team coded the first five interviews line by line. According to Corbin and Strauss (1990), initial coding allows researchers to identify themes from their data. Numerous studies demonstrate that line-by-line coding allows researchers to make sense of large amounts of data from interviews and provides a foundation for developing sociological theory (Charmaz 2008;

Corbin and Strauss 1990; Glaser and Strauss 1967). To ensure reliability, team members met to discuss preliminary codes and develop a codebook before coding. Discrepancies in

12 coding were discussed during team meetings. The interviews were then analyzed using focused coding, and the most frequent themes were carefully inspected. Prior research suggests that this coding phase allows researchers to identify the themes that best fit the guiding questions (Charmaz 2008; Corbin and Strauss 1990).

Our project also adhered to the Institutional Review Board (IRB) guidelines established by the University of Akron. Interviewees completed a consent form with our cultural broker's guidance if they needed it translated into Nepali. All materials connected to the project are stored on a password-protected cloud-based server, which helped ensure participant confidentiality. Demographic information, including age, religion, and caste, was collected from community members, and stored on a password-protected server.

Each of the providers also completed consent forms and had the option to allow the research team to use their names in publications or ensure this information remains confidential. At any time, interview participants could contact a member of the research team and have their information destroyed.

Community Member Demographics

The sample included men (55%) and women (45%). The average age of the participants is 40, with a range of 19 to 70. Most of the sample identified as Hindu (34 percent), followed by Christianity (30 percent), Kirat (23 percent), and Buddhist (14 percent). The Brahmin caste composed 23 percent of the sample, and the Chhatriya caste consisted of 24 percent of the sample. The largest caste is the Vaisya, which composed

30 percent of the sample. Finally, the Shudra comprised the remaining 23 percent of the sample2.

Table 3: Summary Statistics Demographic Mean/Percent Gender Male 55% Female 45% Age 40 Religion Christian 30% Hindu 34% Kirat 23% Buddhist 13% Caste Brahmin 23% Chhatriya 24% Vaisya 30% Shudra 23% Total 100%

Provider Characteristics

One-third of the providers worked for organizations that provided the

Bhutanese/Nepali community with general social services (35 percent). Just under one- third worked for community health centers (30 percent). One-fifth worked for resettlement agencies (20 percent). Only a few worked at a behavioral health center (10 percent), and one person was from law enforcement. The majority of the providers were women (60 percent).

2 Contemporary Bhutanese and Nepali society conform to the caste system. The highest castes are the Brahmin and Chhatriya. This caste is composed of scholars, administrators, and priests. The lower castes are the Vaisya and Shudra, which consists of artisans and laborers (Gellner 2007).

Table 4: Provider Characteristics Demographic Frequency Percent Organization Type Behavioral Health Services 2 10% Community Health Center 6 30% Law Enforcement 1 5% Resettlement Agency 4 20% Social Services 7 35% Gender Male 8 40% Female 12 60%

OVERVIEW OF CHAPTERS

This dissertation includes three chapters that have been written in journal article- style to be submitted for publication. Each of the three chapters written as independent articles guided by unique research questions related to the central question of “How does caste status shape the resettlement experiences of Bhutanese/Nepali refugees?”

References are compiled at the end of the document to meet the formatting guidelines.

The second chapter, "History and Culture" was written in addition to the three journal- style chapters and covers topics associated with significant events in Bhutan: the expulsion of the Southern Bhutanese to Nepal, life in the camps, the resettlement process, and the caste system.

The third chapter of this dissertation, "Caste as a Fundamental Cause of Mental

Health," uses fundamental causes and cultural health capital (CHC) to examine health inequalities within the Bhutanese community. I employ Link and Phelan’s (1995) theory of fundamental causes to illuminate how social inequalities shape health outcomes for members of the Bhutanese/Nepali community. On one hand, members of lower castes have access to fewer resources than members of higher castes and may live in conditions

15 that put them at risk for developing a mental health condition (Furr 2005; Patel 2012;

Subedi 2016b). On the other hand, most refugees feel the caste system will affect them to a lesser extent upon resettlement, and many resettled Bhutanese report that gender inequalities between men and women are the only caste that persists (Halsouet 2013;

Patel 2012).

In the fourth chapter, "Remnants of the Caste System and Barriers to Treatment,"

I examined how the caste system's persistence impacts access to social services in the

Akron area, focusing on the resettlement process, access to public health information, as well as health-seeking behaviors. Integration illustrates how sources of stress related to acculturation may exacerbate existing medical conditions and present barriers to medical care (Ager and Strang 2008; Bennett et al. 2008; Subedi 2016b). I also argue that the

Bhutanese have a different understanding of mental health, making Western forms of treatment problematic (Ao et al. 2012; Cochran et al. 2013; Dutton 2011; Kohrt et al.

2012).

The fifth chapter, "Culturally Competent Mental Health Treatment," evaluates implementing a culturally competent mental health treatment. I argue that mental health should be discussed in safe spaces such as an English as a second language classroom or with a community leader. Further findings demonstrate that mental health can be improved by expanding social services, practicing religion, and engaging in community gardening. Chapter Six, Conclusions, outlines the theoretical contribution, policy implications, and limitations of this project.

CHAPTER II

HISTORY AND CULTURE

Bhutan is a small landlocked kingdom positioned between China and India. This

Himalayan nation has a population of nearly 900,000 and is also the smallest country in

South East Asia (Hutt 2005; Rizal 2004). Dense forests cover more than half of the nation, and the largest city only has a population of 25,000 (Hutt 1996). Bhutan has struggled to secure the borders with India and China (Dhungana 2010; Evans 2010; Hutt

2005). Evans (2010) asserts that Bhutan has been in negotiations with China for decades over the northern border's demarcation. The southern border developed due to conflicts with India and Colonial Britain. Prior scholarship has found that Bhutan also signed treaties with both nations to avoid conflict, which led to a dependency on India for trade

(Evans 2010; Loescher and Milner 2005; Penjore 2004). Despite constant friction with these neighbors, Bhutan has maintained its independence throughout history and has avoided conflicts including colonization from European powers, both of the World Wars, as well as violent nationalist movements (Mathou 2000; Penjore 2004; Sinpeng 2007).

Rizal (2004) asserts that King Jigme Wangchuk manages the government, and his rule is based on heredity. Numerous studies assert Bhutan's monarchy differs dramatically from other South East Asian monarchies, which are founded on the belief that the monarch is given powers from a divine being (Hutt 2005; Mathou 2000;

Pellegrini and Tasciotti 2014). According to Mathou (2000), the king of Bhutan is a

17 secular monarchy. He is granted power through ancestry that can be traced back to

Tibetan monarchs. Bhutan also has a National Assembly, consisting primarily of elected officials (Mathou 2000; Sinpeng 2007). The national assembly functions as the nation's legislature, but the monarchy maintains significant control over the laws they develop

(Hutt 2006; Mathou 2000; Rizal 2004). Furthermore, several studies indicate that most government officials elected to the national assembly are members of the ethnic majority

(Hutt 2006; Mathou 2000; Sinpeng 2007). The Bhutanese government has remained firmly under the king's control, and elections have resulted in policies that favor the majority (Hutt 2006; Mathou 2000; Rizal 2004; Sinpeng 2007).

The population of Bhutan consists of more than a dozen different ethnic groups, and each group has its own unique culture and traditions (Patel 2012). Each of these groups practices their own religious traditions and speaks their own language (Rizal

2004). These ethnic groups are subgroups of four more significant categories (Patel 2012;

Rizal 2004). Bhutanese living in the Northern, Eastern, and Western regions of Bhutan are the ethnic majority (Dutton 2011; Hutt 2005; Rizal 2004). The Southern Bhutanese3 of Nepali descent are the racial minority, and southern cultural traditions differ dramatically from the other ethnic groups (Dutton 2011). For example, the Southern

Bhutanese still practiced Hinduism and retained their native Nepali language (Dutton

2011; Hutt 2006). During the 1990s until 2016, nearly 100,000 Southern Bhutanese were

3 Numerous studies often refer to the Southern Bhutanese as Lhotshampa, which means people of the South (Dutton 2011; Hutt 2005; Rizal 2004). However, I avoid using this label because many of our participants feel that it fails to accurately describe their cultural heritage, and other ethnic groups living in the south who were exiled from Bhutan. Instead, I refer to our participants as Southern Bhutanese or Bhutanese of Nepali descent.

18 expelled from their home country, which comprised roughly one-sixth of the entire nation's population (Hutt 2005).

Bhutanese Culture and Ethnic Relationships

Prior research has found that the Bhutanese government accommodated the amalgamation of ethnic groups for centuries (Hutt 2005; Rizal 2004). During the 18th and 19th centuries, there was seldom tension between ethnic groups, and the country remained a peace for nearly a century (Hutt 1996, 2005; Rizal 2004). Each region of

Bhutan had autonomy over its governments and was not united under the Bhutanese monarchy until the 1950s. During this time, the fledgling kingdom allowed each area to maintain its autonomy and enacted policies to strengthen the nation's economy (Hutt

2005). However, by the 1980s, the monarchy's attitude shifted dramatically when the politically elite Northern Bhutanese gained significant control over the government and forced their ideology onto the rest of the Bhutanese (Rizal 2004). For instance, many of the ethnic groups in Bhutan identify with the hegemonic culture, which is expressed by practicing Buddhism, speaking the Dzongkha language, and adopting the Northern style of dress (Hutt 2005; Pellegrini and Tasciotti 2014). Hutt (1996) asserts that intermarriage between ethnic groups is common, and most subscribe to an identity grounded in

Buddhist traditions.

Southern Bhutanese originally migrated to Bhutan from Nepal and performed manual labor such as farming and logging (Dutton 2011; Hutt 2005). Several studies suggest that Nepali agricultural communities formed the backbone of Bhutan's economy and Southern regions produced most of the country's food (Dutton 2011; Hutt 1996;

Pellegrini and Tasciotti 2014). Northern portions of the country were mountainous, and

19 large-scale agriculture would have been challenging to implement. Hutt (2005) suggests that the initial Nepali migration to Bhutan began during the late 1800s, and Bhutan has experienced a steady influx of Nepali immigrants until the 1980s. The Bhutanese government frequently invited Nepali families to settle along the southern border (Dutton

2011; Rizal 2004). Licensed contractors hired by the Bhutanese government to improve the region's infrastructure also settled in Bhutan (Dutton 2011; Hutt 1996). Many of these contractors began to accumulate a great degree of wealth and became highly influential in local politics (Dutton 2011; Hutt 2005; Rizal 2004). Hutt (1996, 2005) also suggests that

Bhutan's Southern regions were allowed to manage their affairs for decades without interference from the monarchy.

During the 1800s, tensions between colonial Britain and India were an earlier cause of Nepali mass migration into Bhutan and shaped many of the Bhutanese government's policies. In 1864, Bhutan went to war with British colonists settling in India over access to the Bengal Duars region (Evans 2010; Hutt 2005; Penjore 2004; Sharma

2014). The Anglo-Bhutanese war ended a year later with the signing of the Treaty of

Sincula (Evans 2010; Penjore 2004). According to Evans (2010), the treaty gave England the Duars region, but Britain had to pay an annual fee to the Bhutanese government. The

British government enacted policies pushing Nepali peasants living in Darjeeling and

Sikkim to migrate to Bhutan (Evans 2010; Hutt 2005). Farmers often struggled to pay the taxes British governors demanded (Evans 2010; Hutt 2006). These policies continued to fuel the migration of thousands of Nepali people into Bhutan's Southern regions (Evans

2010; Hutt 1996).

Nepali migrant workers were granted full citizenship in the late 1950s. Migrants were eligible for citizenship if they owned land and resided in the country for at least a decade (Dutton 2011; Hutt 2005; Rizal 2004). During this period, Nepali immigrants were given a tax break, which further encouraged more migrants to settle in Bhutan

(Dutton 2011). Government policies intended to integrate Nepali immigrants into the dominant culture. Southern Bhutanese were trained to hold positions in government and married people belonging to the Buddhist majority (Dutton 2011; Hutt 1996; Rizal 2004).

However, the political elites began to feel that Nepali values clashed with the cultural norms followed by the ethnic majority (Hutt 1996; Rizal 2004).

King Jigme Singye Wangchuk took control of the monarchy in 1972 and began to dismantle Bhutan's legacy of cultural pluralism (Rizal 2004). Under his leadership,

Bhutan enacted policies that led to a resurgence of Buddhist values and social norms.

Numerous studies have found that King Jigme Singye felt that Bhutan was too small to enforce policies that would uphold cultural diversity (Dutton 2011; Evans 2010; Loescher and Milner 2005; Rizal 2004). Furthermore, he believed that Bhutan needed to unite under one common cultural identity to stymie incursions from China and India (Evans

2010; Mathou 2000; Penjore 2004; Sinpeng 2007). King Jigme Singye also modernized

Bhutan, which was consistent with his predecessors (Hutt 2005; Pellegrini and Tasciotti

2014). However, the expansion of industry undermined the Southern Bhutanese's farming economy (Evans 2010; Pellegrini and Tasciotti 2014).

History of the Bhutanese Ethnic Cleansing

The Northern Bhutanese feared losing their ethnic identities and becoming a minority in their nation. According to Pellegrini and Tasciotti (2014), the Southern

Bhutanese population grew much quicker than the rest of the country, eventually overtaking the Buddhist majority. Reports conducted by the royal government indicate that there had been a steady increase of Nepali immigrants, and they also had a much higher fertility rate than the rest of the country (Loescher and Milner 2005). A census conducted in the 1980s found that the Southern Bhutanese composed approximately 45 percent of the population, but the ethnic majority only constituted 48 percent of Bhutan's inhabitants (Dutton 2011; Loescher and Milner 2005). Furthermore, the Nepali immigrants were believed to be bringing democratic ideas with them as they immigrated to Bhutan, which the Royal government felt opposed their monarchy's abilities to exert control over the country (Hutt 2005; Rizal 2004).

The monarchy was also concerned about the land movements taking place in neighboring countries. Dhungana (2010) asserted that people of Nepali descent began a series of protests to break off from India and Bengal, demanding a new self-governing nation called Gorkha separate from both countries. The Darjeeling area has a booming economy, and most workers were employed on tea plantations or in the logging industry

(Besky 2017; Sharma 2014). However, Nepali laborers working in the Darjeeling district were inadequately paid, and most people believed that a revolution would bolster their economic wellbeing and cultural identities (Besky 2017; Rizal 2004). Demonstrations related to these movements often became violent, and conflict frequently erupted in the

Darjeeling district of Bengal (Dhungana 2010; Hutt 2005; Rizal 2004). Eventually, more radical movements called for creating a Greater Nepal, which would establish a country composed of all regions where the Nepali language is spoken (Besky 2017; Hutt 2005;

Rizal 2004).

These political movements further fueled Northern Bhutanese distrust of people of Nepali descent (Dhungana 2010; Hutt 2005). However, land movements did not take root in Bhutan, and Southern Bhutanese politicians were more concerned about the monarchy maintaining control over Bhutan (Hutt 2005; Rizal 2004). Bhutanese administrators were aware of the movements taking place in India and Bengal and wanted to find a better solution for apprehensions regarding the development of an independent Gorkha or Greater Nepal (Rizal 2004). It would be challenging to create a nation composed of all Nepali speakers because of cultural differences between regions that would comprise Greater Nepal (Rizal 2004). For instance, most of the people living in the Darjeeling area described themselves as belonging to the Gorkha people who followed their own traditions (Besky 2017).

Based on these fears, the Northern Bhutanese enacted a series of discriminatory policies to prevent Southern Bhutanese migration. First, the monarchy passed "The

Marriage Act," which stripped Southern Bhutanese women of their citizenship and government benefits if they were married to Bhutanese men (Dutton 2011; Hutt 1996).

Next, the Bhutanese government passed the citizenship act, which forced Bhutanese of

Nepali descent to prove they were legally in the country (Dutton 2011; Hutt 2005; Rizal

2004). According to Dutton (2011), the Southern Bhutanese could prove their citizenship based on (a) original tax documents from the 1958 citizenship act, (b) documentation of naturalization by living in Bhutan for at least twenty years, or (c) proficiency in the

Dzongkha language and Northern Bhutanese history.

In 1988 the Northern Bhutanese conducted a special census in the Southern

Region of Bhutan (Dutton 2011; Hutt 2005). According to Dutton (2011), Bhutanese of

Nepali descent could be reclassified into seven different categories: (F1) Genuine

Bhutanese, (F2) Returned Migrants, (F3) Not Counted, (F4) Non-National Woman married to a Bhutanese Citizen, (F5) Non-National Man married to a Bhutanese Citizen,

(F6) legally adopted children, and (F7) Non-Nationals and illegal immigrants (Dutton

2011; Hutt 2005). Numerous studies have found that the government removed citizenship from thousands of families who used tax documents as proof, and they were reclassified as illegal immigrants (Dutton 2011; Hutt 2005). The Northern Bhutanese also disseminated propaganda declaring that Bhutan was being flooded by illegal migrants of

Nepali descent who were believed to have come to the country for free healthcare and education (Evans 2010).

In 1989, the monarchy enacted the "One Bhutan, One People Act" to reform

Bhutanese society to be more consistent with Northern Bhutanese values while eroding the traditions followed by the non-dominant culture (Dutton 2011; Rizal 2004). Research conducted by Hutt (1996) has found that the Nepali language was removed from the curriculum in schools throughout Bhutan. The government stressed students should focus on learning Dzongkha and English. All Bhutanese were forced to adopt the Northern dress code called Driglam Namzhag4, and individuals who did not wear the appropriate garments outside of their homes would encounter a fine or imprisonment (Dutton 2011;

Hutt 2005). Furthermore, individuals who did not adhere to the dress code experienced physical violence from Bhutanese soldiers (Hutt 1996).

4 Prior research suggests that men were required to wear a traditional robe called a gho, and women were required to wear a dress called a kira (Hutt 1996). Furthermore, these garments were typically worn during Buddhist ceremonies or when dealing with government officials (Evans 2010; Mathou 2000).

Bhutanese policies started to produce feelings of unrest, but the monarchy silenced any criticism of their policies (Hutt 2005, 2006; Rizal 2004). For instance, Hutt

(2005, 2006) indicates that Tek Nath Rizal was a government official who attempted to alert the king to growing discontent in Southern Bhutan. According to Evans (2010),

Rizal brought these concerns to the monarchy at the request of the Southern Bhutanese he represented, who were worried about the special census and government policies. Rizal urged the monarchy to stop government policies that marginalized Bhutanese of Nepali

Descent (Dutton 2011). The monarchy stripped Rizal of his office and imprisoned him for several days (Dutton 2011). After his release from prison, Rizal fled to Nepal, resisting the cruel policies enacted by the Northern Bhutanese government, and encouraged Southern Bhutanese dissent in Bhutan (Hutt 2006).

Rizal founded “The People’s Forum for Human Rights”, which printed short leaflets (Hutt 1996). One document called “Bhutan: We Want Justice” argued that

Southern Bhutanese needed to take a stand to protect their rights, which allowed them to embrace their Nepali identity and culture (Evans 2010; Hutt 1996). In 1989, Rizal was seized by the Nepalese Police force and was extradited to Bhutan (Hutt 2005). In Bhutan,

Rizal spent roughly three years in prison before the monarchy convicted him of committing treason (Dutton 2011). Several studies suggest that Rizal remained behind bars for nearly a decade and returned to Nepal after his prison release (Dutton 2011).

According to Evans (2010), Rizal also worked with the Students' Union of Bhutan, responsible for organizing peaceful protests throughout Bhutan. Furthermore, the

Students' Union was responsible for disseminating the pamphlets about human rights and

25 urged the government to repeal policies that marginalized Bhutanese of Nepali descent

(Evans 2010; Hutt 1996).

Prior research also found that Bhutan People's Party (BPP) was formed in the

1990s, and its mission was also to attain civil rights for Bhutanese of Nepali descent

(Evans 2010; Hutt 2005). However, BPP differed dramatically from the other activist groups and adopted violent forms of protest modeled on Gorkhaland extremists in India and Bengal (Evans 2010). The BPP was responsible for the murder of government officials and threatened to kill supporters of the monarchy or Southern Bhutanese who did not support their organizations (Evans 2010). The BPP forced Bhutanese of Nepali descent to make monetary donations to their movement and were responsible for attacking families who did not comply with their commands (Evans 2010). There are several reports of BPP members carrying out beheadings, kidnapping, and torture (Evans

2010).

During the 1990s, a series of protests erupted throughout Bhutan based on the belief that Bhutanese of Nepali descent should be given equal rights (Dutton 2011; Hutt

2006; Rizal 2004). Several organizations including (a) The People’s Forum for Human

Rights, (b) the Bhutan People’s Party, and (c) Students’ Union of Bhutan, were responsible for organizing public demonstrations throughout Bhutan. These were the largest protests to have ever taken place in Bhutan and often remained peaceful

(Lundström and den Uyl 2010). Bhutanese demonstrations were heavily influenced by democracy movements sweeping eastern European nations (Hutt 1996, 2005).

Occasionally, protests erupted in violence, with protestors and the Bhutanese military contributing to the violence (Hutt 2005). Several studies have found that activist attempts

26 to resist the monarchy’s policies were met with acts of physical violence, imprisonment, and torture (Dhungana 2010; Dutton 2011; Pellegrini and Tasciotti 2014).

The Bhutanese military and police force identified thousands of people who were believed to have contributed to protests (Dutton 2011; Hutt 2005). Suspected demonstrators were frequently detained for questioning, imprisoned without trial, and tortured (Evans 2010; Hutt 2005). According to Dutton (2011), protesters encountered harsh conditions in prisons, were seldom brought to trial, and families could not visit incarcerated relatives. Additionally, inmates were denied the ability to practice Hindu religious traditions and were forced to attend Buddhist prayer ceremonies (Dutton 2011).

Furthermore, the monarchy retaliated against protesters through attacks on Southern

Bhutanese homes and businesses (Dutton 2011; Loescher and Milner 2005; Shrestha

2011). The royal military frequently burned down property owned by Bhutanese of

Nepali descent (Loescher and Milner 2005). The royal government also closed down more than half of the schools in Southern Bhutan and suspended access to healthcare throughout the region (Dutton 2011; Shrestha 2011).

In 1991, the Bhutanese National Assembly passed a decree evicting any individual considered an anti-national (Dutton 2011). Southern Bhutanese refugees frequently signed documents stating they left the country voluntarily, but the Royal government often coerced them to complete them (Dutton 2011; Hutt 2005; Loescher and

Milner 2005). For instance, Lundstörm and Den Uyl (2010) suggest that migrants were often forced to complete “voluntary” migration forms at gunpoint. Hutt (1996) further indicates that individuals were frequently videotaped announcing that they left the country on their autonomy.

Bhutanese refugees needed to pass through India before establishing camps in

Nepal (Dhungana 2010; Rizal 2004). Roughly two-thirds of Bhutan shares a border with

India or China, and Bhutanese refugees were not permitted to settle within the Indian borders (Hutt 2005; Rizal 2004). According to Dhungana (2010), the Indian government also feared an influx of Southern Bhutanese settling within their borders would exacerbate the violent Gorkhaland Movement. Instead, armed Indian soldiers corralled

Southern Bhutanese refugees onto trucks, and refugees were either transported to Nepal or returned to Bhutan (Dhungana 2010; Hutt 2005; Rizal 2004). The Indian Military also prevented people resettled in Nepal from returning to Bhutan (Dhungana 2010).

Bhutanese expelled to Nepal held a peace march from the camps back to Bhutan, but

Indian police arrested them after refugees crossed the border (Hutt 2005). The Indian police eventually forced individuals participating in the demonstration to return to Nepal

(Hutt 2005). According to Dutton (2011), no refugees have successfully returned to

Bhutan by crossing through India.

The Indian government worked to remain on friendly terms with Bhutan, further exacerbating the ethnic cleansing (Dhungana 2010). The Indian government influenced the Bhutanese government due to a 1949 treaty favoring India (Rizal 2004). Based on the peace agreement, India was empowered to exploit Bhutan’s natural resources, arrest

Bhutanese activists, and station security forces along the border (Rizal 2004).

Furthermore, the Indian government continued to provide Bhutan with financial support to contend with the refugee crisis and silence Southern Bhutanese protests (Rizal 2004).

On the other hand, India had a tense relationship with Nepal (Hutt 2005; Loescher and

Milner 2005; Rizal 2004). According to Hutt (2005), Nepal’s communist party embraced

28 an anti-Indian ideology and believed that Nepal would eventually need to go war with

India. In general, the Indian government seldom intervened on behalf of the refugees due to support for the Bhutanese government and friction with the Maoist regime in Nepal

(Dhungana 2010; Hutt 2006; Rizal 2004).

Table 5: Timeline of the Ethnic Cleansing of the Southern Bhutanese 1860 – 1940 Nepali workers immigrate to Bhutan 1956 Nationality Law grants Nepali migrants citizenship 1980 Wangchuck Monarchy conducts census and fears losing power 1980 Marriage Act, Nepali women, married to Bhutanese men, lose citizenship 1985 The government passes the Citizenship Act and classification system 1988 Special Census branding Bhutanese of Nepali descent as non-nationals 1989 One Bhutan One People Act bans Nepali language and culture Protests erupt throughout Bhutan, which led to the arrest of thousands of 1990 Southerners 1991 Thousands of Southern Bhutanese immigrate to Nepal 1997 Legislation passed that relatives of Southern Bhutanese can be expelled (Organized by author, based on Dutton 2011)

Life in the Camps

During the 1990s, Bhutanese refugees settled within several camps in the Jhapa and Morang districts of Nepal including (a) Timai, (b) Goldhap, (c) Beldangi – I, (d)

Beldangi – II, (e) Beldangi – II Extension, (f) Sanischare, and (g) Khudunabari (Hutt

2005; Patel 2012). Bhutanese refugees were forced to settle in proximity to small cities such as Damak and Budhabare (Dutton 2011). Refugees initially built huts, which eventually became refugee camps managed by the United Nations. Refugee camps held nearly 90,000 Southern Bhutanese refugees at the pinnacle of the ethnic cleansing in

Bhutan (Dutton 2011; Hutt 1996). Furthermore, almost 15,000 refugees of Nepali descent are believed to reside in other countries such as northeast India and West Bengal (Hutt

1996; Loescher and Milner 2005). Several reports have found that the average family size

29 was four people (Dutton 2011). Furthermore, the camps were split almost evenly between women (49.7 %) and men (50.3 %) (IOM 2008). According to Patel (2012), several refugee camps have been consolidated with the tertiary resettlement of refugees into western nations, and many refugees were forced to relocate within Jhapa and Morang districts. Only the Sanischare and Beldangi refugee camps remain open, and the remaining 18,000 refugees are typically ineligible or do not want to be resettled (United

Nations High Commissioner for Refugees 2015).

The United Nations High Commissions maintained all seven refugee camps for

Refugees (UNHCR). Refugees living in camps were provided with a range of services by the UNHCR, which were sometimes of higher quality than nearby villages (Dutton 2011;

Loescher and Milner 2005; Shrestha 2011). Children were often given a free primary education until the tenth grade but needed to pay for additional schooling (Dutton 2011;

Loescher and Milner 2005). Dutton (2011) demonstrates that refugees also had better access to healthcare than surrounding communities, which was managed by the

Association of Medical Doctors of Asia. However, refugees living in the Jhapa district had dramatically higher rates of anxiety and depression than the surrounding Nepali communities (Dutton 2011; Shrestha et al. 2014; Van Ommeren et al. 2001). Mental health disparities were related to the traumatic life events the Southern Bhutanese experienced with their flight from Bhutan (Shrestha et al. 2014; Van Ommeren et al.

2001). Several studies also have found that refugees suffered from a range of physical health conditions, including anemia, tuberculosis, malaria, and measles (Dutton 2011;

Patel 2012).

According to Dutton (2011), the time spent in the refugee camps often exacerbated many of the health conditions refugees developed before fleeing Bhutan.

Numerous reports assert that refugees consumed a repetitive and imbalanced diet, often devoid of proteins and dairy products (Dutton 2011). Refugees could often purchase meats from surrounding communities, but refugees were often unable to afford proteins

(Dutton 2011; Loescher and Milner 2005). Indeed, malnutrition was common in the camps and associated with vitamin deficiency, which resulted in the nervous system's impaired functioning (Dutton 2011). A variety of studies have also found that refugees living in the camps consumed dangerous amounts of alcohol, which was used to cope with untreated trauma (Luitel et al. 2013). Luitel et al. (2013) have found that Southern

Bhutanese refugees consume hazardous amounts, which often exceeded the amount consumed by problem drinkers living in western countries. While in camps, men were more likely to engage in problem drinking5 than women (Luitel et al. 2013).

Several studies have found that the Southern Bhutanese encountered impoverished conditions in camps such as inadequate food rations, electricity, lack of clean water, and few opportunities for work or vocational training (Dutton 2011;

Lundström and den Uyl 2010; Rizal 2004). Many of the camps were underfunded, which led to shortages in medication, suspension of poverty relief programs, inability to maintain educational curriculum, and inadequate healthcare (Dutton 2011). Deficits in the

UNCHR budget were responsible for the inadequate funding camps received (Dutton

2011). Furthermore, a report conducted by Lundström and den Uyl (2010) found that

5 Alcohol consumption was banned by the United Nations in the camps. However, many Bhutanese/Refugees continued to brew their traditional alcohol (raksi) in the camps. Tika's story is presented in chapter three and she created a business selling alcohol to afford her daughters medical treatment.

31 most refugees lived in temporary housing constructed from bamboo, which frequently caught fire during the summer. The International Organization for Migration (Schininà et al. 2011) indicated that huts were diminutive in size (6 x 4 meters) but frequently had to accommodate six or more people. Bhutanese refugees experienced a prolonged stay in these conditions and often endured decades living in camps (Adhikari et al. 2015; Dutton

2011). These conditions fostered feelings of uncertainty about the future associated with being stateless, which damaged resources to cope with stressors (Adhikari et al. 2015;

Dutton 2011; Shannon et al. 2015).

During their time living in the camps, young adults often encountered difficulties finding employment and faced discrimination from surrounding communities (Dutton

2011; Loescher and Milner 2005). Dutton (2011) indicated that people living in Damak felt that Bhutanese refugees received preferential treatment due to the use of services provided in the camps. Adults were not permitted to work in the refugee camps and struggled to find meaningful employment in neighboring communities (Dutton 2011; Ott

2013; Shannon et al. 2015). Refugees reported that being unable to work undermined their sense of self-worth and fostered feelings of hopelessness (Dutton 2011). Loescher and Milner (2005) found that adults were often only employed in socially devalued occupations and provided local villages with cheap sources of labor. Bhutanese of Nepali descent were not welcomed into Nepalese communities. Nepali villages complained that

Bhutanese refugees were responsible for taking jobs from their communities and driving down wages (Dutton 2011; Loescher and Milner 2005). Additionally, Nepali locals believed that the refugees were responsible for increases in crime (Dutton 2011; Loescher and Milner 2005).

There is also substantial evidence to suggest that Bhutanese refugees were exposed to stressful life events including the ethnic cleansing in Bhutan and hostile conditions from host societies (Dutton 2011; Hutt 2005; Rizal 2004). Members of the refugee community encountered acts of violence such as child labor, torture, rape, and violence (Luitel et al. 2013; Lundström and den Uyl 2010; Van Ommeren et al. 2001). A report conducted by Lundstörm and den Uyl (2010) indicates that human trafficking was commonplace in the camps, and violence against women and children was seldom reported to the authorities.

Between 1996 through 2006, political instability around Damak added to the violence (Dutton 2011; Hutt 2005). The Communist Party of Nepal (CPN; Maoists) wanted to take the government's control and establish a military power capable of repelling incursions from neighboring countries (Dutton 2011; Hutt 2006). According to

Hutt (2005), the Nepali government failed to counter Maoist revolutionaries, and civil war engulfed the country. In 2001, insurgents murdered King Birendra and seized power from the Nepali government (Hutt 2005). Bombings and assassinations were commonplace in regions surrounding refugee camps (Dutton 2011). Maoist fighters used refugees to recruit more soldiers, which further strained the crumbling Nepalese government (Loescher and Milner 2005). Nepal branded these insurgents as a terrorist organization, and military conflicts became commonplace (Hutt 2005). Several studies have found these conditions undermined refugee feelings of safety and interfered with delivering supplies to the camps (Dutton 2011). Several governments came to power in

Nepal in the 1990s, and each regime wanted the Bhutanese administration to reclaim the people they exiled from Bhutan (Hutt 2005). During this period, there were also

33 negotiations between Bhutan and Nepal about allowing the refugees to return home (Hutt

2005; Rizal 2004). However, the Nepalese government remained in a state of political upheaval for decades ending negotiations between Bhutan and Nepal (Hutt 2005;

Loescher and Milner 2005)

There is substantial evidence that the caste system was outlawed in refugee camps by the United Nations but continued to shape Bhutanese/Nepali refugees' lives. Although members of lower castes still encounter discrimination, many reported less discrimination from higher castes during their time in the camps (Patel 2012). While living in Bhutan, members of lower castes were forbidden from engaging in some interactions with higher castes members. Some upper castes living in camps still tried to follow the caste system to maintain their spiritual purity (Patel 2012). Nevertheless, camp life made it difficult to follow appropriate social norms. Outside organizations in refugee camps may have also impacted the caste system's influences on lower caste members. There is some evidence that religious organizations worked to convert refugees to Christianity, but Christian beliefs are incompatible with the caste system (Halsouet 2013; Kohrt et al. 2012; Patel

2012). Western organizations were also responsible for education in the camps, which increasingly led children to perceive caste differently than their parents (Patel 2012).

Bhutanese refugees experienced traumatic life events associated with their flight from Bhutan and the decades spent in the camps. Before they fled to the camps,

Bhutanese/Nepali experienced numerous encounters with violence, imprisonment, and torture (Hutt 2005; Lundström and den Uyl 2010; Rizal 2004). Decades of living in refugee camps located in Nepali exposed Bhutanese refugees to new stressors such as inability to find stable employment or culturally competent medical treatment (Dutton

2011; Shannon et al. 2015). Refugees living in camps also reported encounters with sexual violence, rape, and human trafficking (Dutton 2011; Lundström and den Uyl

2010). Bhutanese of Nepali descent encountered trauma when Bhutan and Nepal prevented them from gaining citizenship, which further undermined feelings of control

(Adhikari et al. 2015; Hutt 2005; Rizal 2004). In general, refugees experienced a range of premigration stressors, which often persisted upon resettlement into another society.

The Resettlement Process

Since 2007, thousands of Bhutanese refugees have been resettled into seven western countries including: The United States, Canada, Australia, New Zealand,

Netherlands, Norway, and Denmark (Dutton 2011; Lundström and den Uyl 2010). Prior research found that the U.S. initially accepted 60,000 Bhutanese of Nepali descent, with the remaining countries resettling approximately 10,000 refugees (Dutton 2011;

Lundström and den Uyl 2010; Shrestha 2011). However, at least 30,000 refugees remained in the camps for decades, and the last group of refugees were resettled in 2016

(Dutton 2011; Gurung 2019; Shrestha 2011). According to the UNCR Resettlement

Handbook (2018), the resettlement process serves three functions: meeting the specific needs of individual refugees at higher risk in their countries of origin, providing a sustainable solution for large numbers of refugees, and serving as an expression of international solidarity.

Dhungana (2010) argues that migration organizations such as UNCR and IOM were selective when deciding who could migrate to a new country. For example, refugees needed to apply to be resettled and complete over six months of interviews while still living in the camps (Dhungana 2010; Shrestha 2011). International resettlement

35 organizations sometimes denied families who applied for resettlement, which further prolonged their time in the camps (Dhungana 2010). Inability to exert control over uncertain events exposes refugees to added stress (Pearlin et al. 1981; Thoits 1995).

Individuals belonging to higher castes were often given preference during the resettlement process over lower caste members (Ott 2013). Members of higher castes are more likely to be literate, educated, and have greater access to financial resources than the lower castes (Gellner 2007; Subedi 2016b). Further, government policies often marginalized the lower castes (Bennett et al. 2008; Gellner 2007; Subedi 2016b).

Since 2007, a report conducted by the CDC (2014) indicated that between 5,000 -

15,000 Bhutanese refugees arrived in the United States each year and were resettled in 41 states. The states receiving the most Bhutanese refugees include Pennsylvania, Texas,

New York, Georgia, Ohio, and Arizona (CDC 2014). However, the number of Bhutanese refugees entering the United States has been dramatically reduced with bans from the

Trump administration. Many of the remaining 18,000 refugees are ineligible for resettlement or do not want to be resettled (United Nations High Commissioner for

Refugees 2015). Resettled refugees are also free to migrate to different areas after resettlement and often join existing Bhutanese communities (Ott 2011). Forcibly displaced Bhutanese/Nepali community members often move to Pittsburgh, Columbus, and Akron, where there are large refugee communities (CDC 2014). For instance, numerous reports have found that nearly 5,000 refugees were resettled in the Akron area.

Local agencies estimate that the number of Bhutanese living in the area is around 11,000 because of secondary migration (Anon 2019).

Resettlement of refugees in the United States involves the collaboration of nonprofit agencies and international organizations. The UNCR Resettlement Handbook

(2018) asserts that local agencies are responsible for providing refugees with a range of services, which help them find employment, housing, and medical care. However, government policies increasingly restrict resettlement agencies' abilities to operate due to the distribution of funding, changes in annual quotas of refugees admitted, and developing resettlement programs (UNCR 2018). After the Second World War, the U.S. government restricted most refugee groups' abilities to migrate from Europe. The government prevented refugee immigration from parts of the Middle East and eastern

European nations (Ott 2011; UNCR 2018). In the 1980s, the American government passed the Refugee Act, expanding refugees' ability to gain rights and opened migration for previously marginalized refugee groups (Ott 2011). Refugees migrating to the United

States were given the ability to apply for permanent alien status within a year and citizenship after living in the country for five years (Ott 2011).

Agencies typically offer programs related to reception (e.g., housing, medical appointments, and orientations) or finding employment (e.g., job searches and interviews)

(Ott 2013). Most agencies are dependent on volunteers or caseworkers who are responsible for administering programming to refugees. Caseworkers are also responsible for linking refugees to resources in the community associated with health, education, and employment (Ott 2013; Valtonen 2001). However, numerous studies have found that resettlement agencies are underfunded, and the staff members are frequently stretched too thin (Ott 2013; Shrestha 2011). Caseworkers at resettlement agencies are often responsible for connecting resettled refugees with medical services in the communities,

37 which leaves some conditions untreated (Ott 2011; Pace et al. 2015). Refugees indicate that resettlement agencies are increasingly being provided inadequate services from their caseworkers (Shrestha 2011). Another problem is that refugees who have completed a secondary migration to a new community are often unable to access local providers' services because resettlement policies were intended to keep refugees in the same area over time (Ott 2011). However, the funding once provided to refugees does not follow them when they leave the communities where they were resettled (Ott 2011, 2013).

Resettled refugees report numerous problems finding meaningful employment

(Gurung 2019; Hoellerer 2013; Ott 2013). For example, in Bhutan, people worked in farming, fishing, and sewing, but these jobs were difficult to find upon resettlement in the

United States (Ott 2013). In a qualitative study, Hoellerer (2013) found that resettled

Bhutanese refugees could not find a job because they were struggling to learn the English language. Furthermore, most resettled refugees reported that social service agencies did not offer employment services (Dhungana 2010; Hoellerer 2013). According to Valtonen

(2001), refugees also lack transportation access, which further impairs navigating their host communities. There is also some evidence that refugees who do not speak English struggle to comprehend street signs or follow traffic laws (Gurung 2019). Inability to speak English may create conditions where resettled refugees are involved in traffic accidents.

Another concern reported by resettled Bhutanese refugees is the inability to practice their religion. Numerous studies indicate that refugees were concerned that they would not find a Hindu temple or a Brahmin priest (Dutton 2011; Hodge 2004). Indeed, several studies posit that Brahmin priests were not given priority during the resettlement

38 process even though they have responsibility for organizing collective religious ceremonies associated with birth, death, and marriage (Halsouet 2013; Dutton 2011;

Hodge 2004). Halsouet (2013) found that Hindu rituals were often performed in private residences, and priests were often improperly trained on conducting religious ceremonies.

However, respondents frequently reported that performing religious ceremonies without a temple produced feelings of detachment from their beliefs (Halsouet 2013). According to

Dutton (2011), families were also concerned that they would struggle to maintain their vegetarian diets when they moved to a western country. For example, parents were often worried that school lunches would fail to meet the dietary restrictions associated with practicing Hinduism (Dutton 2011).

The Nepali Caste System

Hodge (2004) indicated that the caste system is based on Hindu religious traditions and may persist upon resettlement into western societies. Sociologists describe the caste system as stratification, which shapes social interactions, employment, and marriage (Bennett et al. 2008; Hodge 2004; Subedi 2011). According to Subedi (2011), the Nepali caste system is a closed system determined through birth, but individuals can be expelled from their caste if they commit a ritual offense (Subedi 2011, 2016b). There is substantial evidence that higher castes are perceived as spiritually pure, but they can become tainted through inappropriate interactions with lower castes members (Subedi

2016b). It is considered unacceptable for the higher castes to marry someone from the

39 lower castes or consume foods prepared by someone from a lower caste6 (Dutton 2011;

Hodge 2004; Subedi 2011).

Spiritually impure actions can cause higher castes to be demoted to a lower caste

(Levine 1987; Subedi 2016b). This loss in social status hampers former upper-caste members' ability to access social and economic resources. Members of lower castes who commit crimes can be enslaved or expelled from the caste system (Levine 1987).

Members of lower castes who are accused of committing crimes often pay higher legal fees and suffer harsher punishments than the higher castes (Levine 1987). Further, individuals expelled from their castes are considered untouchables (Dalits) defined as being casteless (Subedi 2011). There is substantial evidence that untouchables are further marginalized by the rest of society, which often forces them into poverty, prevents them from working, and practicing their religions (Cox 1970). Scholars have also found that untouchables perform poorly on public health measures than people still in the caste system (Bennett et al. 2008).

The caste system is also based on ethnicity, and the Nepali legal system has mandated that every racial and ethnic group be situated in a caste (Bennett et al. 2008;

Patel 2012; Subedi 2016b). Like India, the Nepali caste system was developed to consolidate the Hindu majority's power over ethnic minorities (Levine 1987; Subedi

2011). However, many ethnic groups who do not practice Hinduism have been incorporated into the caste system. This approach benefited Nepal because it allowed migrants from other parts of Asia to integrate with Nepal's cultural and religious beliefs

6 According to Subedi (2011) appropriate marriages are between men and woman from the same caste. Further the consumption of impure food prepared by a member of lower castes are believed to induce symptoms of physical pain, nausea, and vomiting (Dutton 2011; Subedi 2011).

(Levine 1987). On one hand, ethnic minorities of Tibetan descent are often considered members of the middle castes but continue to follow traditions associated with their host societies (Levine 1987). On the other hand, individuals living in the southern plains are members of the Madhesi ethnic group, consisting of Muslims and migrants from India

(Hangen 2017). Most members of this group would be considered lower castes, but an extreme minority of individuals would be identified as belonging to the upper castes.

Each of the different ethnic groups falls into one of four main castes7 recognized by the Nepali legal system called Muluki Ain (Gellner 2007; Levine 1987; Patel 2012;

Subedi 2011). According to Patel (2012), the Muluki Ain is grounded in the four Indian varnas Brahmin, Chhatriya, Vaisya, and Shudra. The upper castes are the Brahmin and

Chhatriya, who wear sacred cords that symbolize their spiritual purity (Levine 1987).

According to Hodge (2004), Brahmins are responsible for carrying out religious ceremonies and form the highest caste. Chhatriya are administrators governing the other castes (Gellner 2007; Hodge 2004; Subedi 2016b). In this dissertation, I refer to the

Vaisya and Shudra as the lower castes who are commoners and servants (Gellner 2007).

A report conducted by Gellner (2007) demonstrates that the Vaisya are merchants, tradespersons, and business owners. Finally, Shudra composes the lowest caste who work as unskilled laborers and serve the higher castes (Bennett et al. 2008; Gellner 2007;

Hodge 2004; Subedi 2016a). According to Hodge (2004), the caste system is intended to benefit each of the groups involved and ensures that society continues to function.

7 Many ethnic groups further define themselves with their own individual castes (Gellner 2007; Levine 1987; Subedi 2016b). Some ethnicities may acknowledge more than 60 different castes. In this dissertation I focus on the four major castes identified by the Nepali legal code, Muluki Ain.

There is also substantial evidence that the caste system intersects with gender and exacerbates social inequalities. Women are viewed as being less pure than men of the same caste (Cameron 1995). On the one hand, women in upper castes may work in various occupations (Cameron 1995). However, women spend more hours than men engaging in domestic labor such as caring for children, cooking, and cleaning (Cameron

1995). According to Misra (2019), many upper caste women engage in care work because they feel responsible for maintaining the caste system.

On the other hand, women in lower castes often work in occupations that are considered too impure for higher caste women. Gender inequalities are often present through the division of lower caste labor. In agrarian communities, men are responsible for doing work such as plowing fields, which offers men longer work hours and better compensation (Cameron 1995; Levine 1987). Women in the same communities engage in underpaid lower-status work such as sowing crops and weeding fields (Levine 1987).

Women in the lower castes are further offered few opportunities for economic advancement through the inability to purchase land, find adequately paying work, and low participation in primary education (Cameron 1995; Stash and Hannum 2001).

During the resettlement process, members of upper castes were given preference over the lower castes, and remnants of the caste system may fuel inequalities within resettled Bhutanese communities (Dutton 2011; Ott 2013). These concerns expose refugees to new sources of stress that manifest themselves upon resettlement into western society. However, higher castes have access to more resources such as knowledge, power, and prestige, which may protect them from stressors associated with their flight from Bhutan and integration into their host society. People belonging to higher castes are

42 more likely to seek treatment for a health condition and utilize available public health information (Bennett et al. 2008; Patel 2012). Members of lower castes are potentially at a higher risk for developing a mental health condition due to working in dangerous occupations, living in squalid conditions, and encounters with discrimination from others

(Gellner 2007; Patel 2012; Subedi 2016b). Ultimately, refugees experience several stressful life events associated with the resettlement process, and they are exacerbated by membership in the lower castes.

CHAPTER III

CASTE AS A FUNDAMENTAL CAUSE

Bhutanese refugees have been resettled in different western nations after fleeing discriminatory policies enacted by the Northern Monarchy. Before resettlement, refugees encountered impoverished conditions in camps such as inadequate food rations, lack of clean water, and few opportunities for work or education (Dutton 2011; Lundström and den Uyl 2010; Rizal 2004). There is substantial evidence that Bhutanese refugees were exposed to stressful life events, including the ethnic cleansing in Bhutan and hostile conditions from their host societies (Dutton 2011; Hutt 2005; Rizal 2004). Prior research indicates that members of the refugee community reported premigration trauma, including torture, rape, and violence (Luitel et al. 2013; Lundström and den Uyl 2010;

Van Ommeren et al. 2001). Upon resettlement, refugees also encountered stressors associated with the immigration process. For instance, several studies suggest that refugees reported feelings of distress while finding work and learning a new language

(Dutton 2011; Kohrt et al. 2012). I argue that caste status functions as a fundamental cause of illness, and members of lower castes have fewer resources to contend with stressors.

Resettled Bhutanese refugees are at high risk of developing a mental illness due to their exposure to traumatic life events (Dutton 2011). Resettled Bhutanese/Nepali

44 refugees often develop depressive symptoms, feelings of anxiety, and somatic disorders

(Kohrt et al. 2009; Luitel et al. 2013; Van Ommeren et al. 2001). Bhutanese/Nepali refugees have a much higher rate of suicide than other forcibly displaced populations, which occurs both in refugee camps and upon resettlement into a western nation

(Adhikari et al. 2015; Ao et al. 2012; Hagaman et al. 2016). Working-aged men who were forced to spend decades in the camps are at the highest risk of committing suicide

(Ao et al. 2012; Hagaman et al. 2016). Several studies have found that members of the

Bhutanese/Nepali community are reluctant to seek mental health treatment because they fear being stigmatized by other people (Ao et al. 2012; Subedi et al. 2015).

Many of these mental health consequences may be exacerbated by membership in a lower caste. Before resettlement, people belonging to lower castes were forced to live in harsh conditions (Furr 2005) and work in dangerous occupations (Patel 2012; Subedi

2011). Fundamental causes can be applied to understand that these conditions put members of lower castes at risk for developing mental health conditions (Link and Phelan

1995). Individuals who have lower caste status are also more likely to encounter stressors associated with discrimination from people who have higher caste status (Dutton 2011;

Patel 2012). There is substantial evidence people from the higher castes are educated, speak English to interact with providers, and work in stable occupations (Bennet et al.

2008; Gellner 2007; Subedi 2016b). Indeed, the upper castes have greater access to resources than lower castes (Gellner 2007; Subedi 2016b). Fundamental causes of illness further indicate that more privileged individuals have access to more resources, which improves their ability to seek treatment for mental health conditions (Link et al. 2008;

Link and Phelan 1995). This paper uses 100 in-depth interviews with the

Bhutanese/Nepali community and 20 provider interviews to understand how the caste system shapes resettlement experiences and functions as a fundamental cause.

LITERATURE REVIEW

Traumatic Experiences in Bhutan

During the late 1980s, the Bhutanese government enacted policies marginalizing

Southern Bhutanese who subscribed to different religious and cultural beliefs than the rest of the country (Dutton 2011; Hutt 2005; Lundström and den Uyl 2010; Rizal 2004).

The hegemonic Northern Bhutanese regime purged southern religion, language, and culture (Dutton 2011; Lundström and den Uyl 2010; Rizal 2004). According to Hutt

(2005), the Wangchuck monarchy feared losing its power to people of Nepali descent who followed different ethnic traditions than the Northern majority. Under the One people One Bhutan Act, the Southern Bhutanese were forced to adopt the language, religion, and style of dress subscribed to by the rest of the country (Hutt 2005; Rizal

2004). These policies forced southern women into marriages with Northern Bhutanese men to protect Buddhist religious traditions (Dutton 2011; Rizal 2004). Protests against the monarchy's oppressive rule exploded throughout Bhutan (Dutton 2011; Hutt 2005).

However, individuals who questioned the government's policies were branded anti- nationals by the monarchy, which led to the torture and imprisonment of thousands of innocent Bhutanese (Dutton 2011; Hutt 2005).

Southern Bhutanese who refused to leave Bhutan or participated in protests were often arrested without trial by the royal military (Hutt 2005; Rizal 2004). Southern

Bhutanese were labeled as anti-nationals, and the government forced their families to leave Bhutan. Thousands of Southern Bhutanese who were forcibly displaced needed

46 sign forms stating that they voluntarily left the country. Further, the monarchy made refugees claim that they did not experience persecution from the government (Dutton

2011). According to Dutton (2011), Southern Bhutanese who were able to stay in Bhutan were further marginalized through additional policies. The monarchy barred individuals who identified as Southern Bhutanese from accessing healthcare, getting an education, and purchasing housing (Dutton 2011). These policies led to the expulsion of hundreds of thousands of Bhutanese from their native country who settled into seven refugee camps throughout the Jhapa District of Nepal (Hutt 2005; Rizal 2004). The first refugees were responsible for creating shacks out of bamboo, but the United Nations eventually devoted their resources to the camps' construction and maintenance (Dutton 2011; Shrestha 2011).

Uncertainty and Statelessness

During their time in refugee camps, Bhutanese refugees lived in harsh conditions and frequently encountered human rights violations (Rizal 2004). Life in the camps was very difficult for refugees who lacked necessities including clean water, adequate food rations, electricity, and shelter (Dutton 2011; Lundström and den Uyl 2010). Numerous studies have found that refugees living in camps were not given opportunities to work or pursue higher education (Dutton 2011; Hutt 2005; Rizal 2004). Refugees who were permitted to work outside the camps reported frequent encounters with discrimination from the Nepali citizens living in the Jhapa District (Dutton 2011; Patel 2012). According to Lundström and den Uyl (2010), human trafficking occurred frequently, and both women and children reported having encounters with violence. Indeed, Southern

Bhutanese living in refugee camps reported rape, torture, and physical abuse (Dutton

2011). Refugees lived in these harsh conditions for decades and continued to encounter violence during their time in Nepal (Dutton 2011; Hutt 2005; Rizal 2004).

Prior research demonstrates that the Southern Bhutanese became stateless people stripped of their nationality, and thousands of refugees were denied citizenship in Nepal

(Hutt 2005; Rizal 2004). According to Hutt (2005), Bhutan and Nepal negotiated giving citizenship to refugees fleeing from Bhutan, and both governments tried to work together to solve the refugee crisis. However, the Bhutanese monarchy enacted legislation preventing the return of Southerners. During their talks with the Wangchuk monarchy, the Nepalese government experienced political instability and remained on the brink of civil war for years (Hutt 2005; Kohrt et al. 2009; Patel 2012). These conditions rendered

Nepal unable to offer citizenship to Bhutanese refugees (Hutt 2005). Negotiations between Bhutan and Nepal eventually collapsed, leaving thousands of Southern

Bhutanese without citizenship or national identity (Dutton 2011; Hutt 2005; Rizal 2004).

In a report conducted by Adhikari et al. (2015), resettled refugees in Columbus, Ohio, indicated that being stateless was the most distressing part of being expelled from

Bhutan.

Downing and Garcia-Downing (2009) indicate that disruptions to routine culture damage feelings of control over life and resources that function as a safety net.

Individuals who report control over forces that may affect their lives are more likely to have a favorable self-concept, which protects them from stressors (Pearlin et al. 1981).

However, being stateless stripped Bhutanese refugees of their ethnic identities and the social norms in their society of origin (Downing and Garcia-Downing 2009). During their time in camps, refugees reported feelings of hopelessness associated with the inability to

48 follow social norms such as taking care of parents, providing for family members, and following gender norms (Dutton 2011; Shannon et al. 2015). Encounters with chronic life strains or persistent stressors negatively impact self-concept, undermining the protective influences of control and self-esteem (Pearlin et al. 1981).

Acculturation Stress and the Stress Process Model

Around 2007, Bhutanese refugees were resettled throughout western societies, including the United States, Australia, Canada, the United Kingdom, New Zealand, and the Nordic nations (Dutton 2011; Lundström and den Uyl 2010). However, this process is still ongoing, and thousands of refugees still live in several of the camps in Nepal (Dutton

2011; Hagaman et al. 2016; Hutt 2005; Rizal 2004). Prior research suggests that resettled refugees encounter a series of new stressors when resettled into their host countries, which often exacerbates trauma associated with their time in the camps (Adhikari et al.

2015; Dutton 2011; Ott 2013). For instance, several studies have found that Bhutanese refugees encounter sociocultural stressors such as separation from family members, learning a new language, and finding meaningful employment (Ager and Strang 2008;

Dutton 2011; Kohrt et al. 2012; Lundström and den Uyl 2010). Newly resettled refugees may also experience a loss in social status while integrating into their host societies such as past credentials or leadership not being recognized (Ager and Strang 2008; Scudder and Colson 1982).

Pearlin et al. (1981) have found that encounters with stress become persisting life strains when individuals do not have the resources to deal with them adequately. Lasting life strains associated with the resettlement process are exacerbated by ongoing trauma caused by premigration stressors (Porter and Haslam 2005; Scudder and Colson 1982).

For example, Bhutanese refugees are likely still experiencing life strains associated with their rapid flight from Bhutan, imprisonment, torture, and encounters with sexual violence (Hutt 2005; Lundström and den Uyl 2010; Rizal 2004). Resettled refugees also face psychological acculturation stressors during the integration process (Scudder and

Colson 1982). Refugees often report feelings of guilt for being resettled while members of their family remain in camps or migrate to other societies (Dutton 2011; Lundström and den Uyl 2010; Shrestha 2011). There is also evidence that newly resettled refugees grieve the loss of their former homes, and some refugees expressed a desire to return to

Bhutan and Nepali (Adhikari et al. 2015; Dutton 2011; Scudder and Colson 1982).

According to Scudder and Colson (1982), refugees cope with acculturation stressors by clinging to traditions, which provides them with a familiar cultural context.

Subscribing to traditions associated with the society of origin minimizes feelings of uncertainty (Downing and Garcia-Downing 2009; Scudder and Colson 1982). Resettled

Bhutanese refugees may cling to the caste system to contend with stressful life events and continuing life strains. On the one hand, Patel (2012) asserts that refugees belonging to lower castes believed that the caste system would not continue to affect them upon resettlement into their host societies. On the other hand, members of higher castes and older adults still believed that the caste system is an essential part of their identities and may cling to the beliefs associated with their society of origin (Dutton 2011; Furr 2005;

Patel 2012).

The Caste System

Contemporary sociologists define the caste system as a social structure where individuals are born into a system of stratification (Subedi 2011). Based on their social

50 hierarchy position, individuals follow a set of norms influencing patterns of employment, education, and marriage (Bennett et al. 2008; Subedi 2011). Modern definitions of caste expand on earlier research because they are centered on the influences caste position has on social life rather than the influences of values, beliefs, and cultures (Subedi 2011).

Caste position is responsible for defining work, marriage, and access to resources

(Gellner 2007; Subedi 2011). Bennet et al. (2008) suggest that the caste system followed by Nepali descent people differs dramatically from other South East Asian countries because groups are defined by their race and ethnicity rather than their religious beliefs.

Indeed, the Nepali government follows Muluki Ain, mandating the entire population follows the caste system and codified discriminatory policies (Patel 2012). Bhutanese of

Nepali descent are aware of the caste they are born into, and racial minorities are marginalized based on their position (Bennett et al. 2008; Gellner 2007; Subedi 2016b).

There is substantial evidence that members of the upper castes (e.g., Brahmin;

Chhatriya) occupy positions of privilege in Nepali communities and are benefiting from government policies that allow them to purchase property and attain higher education

(Bennett et al. 2008; Gellner 2007; Subedi 2016b). Additionally, individuals belonging to the upper castes are employed in prestigious occupations such as academia, medicine, and religion. Individuals belonging to the middle caste are the Vaisya, who work as merchants, traders, and small business owners (Gellner 2007; Subedi 2011). Furthermore, this caste typically does not encounter extreme marginalization by their social position but are not tendered the benefits enjoyed by the upper castes (Bennett et al. 2008; Subedi

2016b)., Individuals belonging to lower castes (e.g., Shudra) are disenfranchised by their social positions and are perceived as existing to serve the upper castes (Gellner 2007;

Subedi 2016a). The lowest castes typically work in the service sector and work as cleaners, leatherworkers, servants, and prostitutes (Bennett et al. 2008; Gellner 2007;

Subedi 2016a).

People belonging to higher castes are viewed as spiritually purer than individuals born into the lower castes (Bennett et al. 2008; Patel 2012; Subedi 2011). Prior research further suggests that higher and middle castes are forbidden from consuming impure substances such as alcohol (Bennett et al. 2008; Dhital et al. 2001). Additionally, members of higher castes who begin to abuse substances are often rushed into treatment because they have violated a social norm that is deeply engrained into Bhutanese culture

(Dutton 2011). Members of lower castes are viewed as impure (Bennett et al. 2008; Patel

2012; Subedi 2011). According to Dhital (2001), individuals belonging to lower castes also consume alcohol during rituals associated with their caste. For instance, individuals belonging to lower castes are permitted to drink at weddings, births, deaths, and seasonal festivals (Bennett et al. 2008; Dhital et al. 2001). Furthermore, individuals belonging to the lower castes perform hazardous work, which often causes injuries or physical/mental health conditions (Bennett et al. 2008).

Caste as a Fundamental Cause

The caste system was banned in the refugee camps, and many governments in

Southeast Asia have taken measures to reduce caste-based discrimination (Gellner 2007;

Patel 2012; Subedi 2011). However, there is substantial evidence that the caste system persists in Bhutan and continues to shape every member of society (Bennett et al. 2008;

Gellner 2007; Subedi 2016a). The caste system followed by Bhutanese of Nepali descent is based heavily on race and ethnicity and is less grounded in Hinduism than other

Southeast Asian nations (Bennett et al. 2008; Subedi 2011). There are numerous ethnic groups in Bhutan, and each of them falls into one of the four major castes Brahmin,

Chhatriya, Vaisya, and Shudra (Gellner 2007; Patel 2012; Subedi 2011). Many scholars define the caste system as an individual's social position that they are born into (Bennett et al. 2008; Gellner 2007; Subedi 2011). Based on their social positions, individuals must work in certain occupations, follow a set of rituals specific to their caste, and avoid certain interactions with lower castes (Bennett et al. 2008; Gellner 2007; Subedi 2016b).

Fundamental cause theory is applied to understand the persistence of health disparities within the Nepali/Bhutanese community. According to Link and Phelan

(1995), fundamental causes are social mechanisms that foster multiple risk factors for becoming sick. In the past, lower castes lived in extreme poverty, had low social status, and worked in hazardous occupations (Furr 2005; Gellner 2007). Fundamental causes further indicate multiple disease outcomes associated with living in these harsh social conditions (Link and Phelan 1995). The lowest caste, Shudra, has a dramatically higher infant mortality rate and performed worse on epidemiological measures than individuals who belong to the higher castes (Bennett et al. 2008; Furr 2005). According to Patel

(2012), the lower castes believed that they were in worse health than members of higher castes, caused by their disenfranchised social status.

There is some evidence that having a higher social status may work against the health of more privileged individuals who experience a "countervailing mechanism"

(Freese and Lutfey 2011; Lutfey and Freese 2005). For example, Freese and Lutfey

(2011) have found that social, economic status failed to provide health benefits and sometimes fostered health problems not experienced by lower-status individuals.

Members of the upper castes are also not permitted to drink in their society of origin, but people of the lower castes often drink alcohol for religious ceremonies (Dhital et al.

2001). When people of upper castes engage in substance abuse, they are rushed into treatment, which may indicate their caste status may not be protective of their mental health. There is also substantial evidence that members of the upper castes experienced a variety of privileges in their host societies before the ethnic cleansing (Bennett et al.

2008; Gellner 2007; Subedi 2016a). However, members of the upper castes may have experienced a more profound drop in status upon being resettled into their host societies

(Dutton 2011), which may worsen medical problems.

Cultural Health Capital

Shim’s (2010) theory of cultural health capital (CHC) can also illuminate health disparities in the Bhutanese/Nepali community. CHC posits that more privileged individuals can better navigate healthcare systems (Gengler 2014; Shim 2010). People higher in CHC can describe medical symptoms to doctors, knowledge of medical terms, and interpersonal communication skills (Shim 2010). Members of the Brahmin and

Chhatriya castes are more likely to speak English, have economic resources, and often have received an education (Subedi 2016b). Capital may tender members of the upper castes with benefits when they seek medical care. People higher in CHC are also more likely to advocate for their treatment and push medical professionals to provide care

(Gengler 2014). Shim (2010) further suggests that the medical system will favor more privileged individuals. Indeed, members of higher castes occupy a position of prestige, and their style of dress, ways of communicating, and occupations still reflect their status

(Gellner 2007; Patel 2012; Subedi 2016a). According to Muralidharan (2016), members

54 of the upper castes often are lighter-skinned, which may help them avoid unconscious bias when dealing with medical professionals and providers (Williams and Mohammed

2013).

CHC also argues that lower-status individuals are less likely to have the skills and resources to seek medical care (Gengler 2014; Shim 2010). For example, people lower in CHC may lack knowledge about medicine and struggle to interact with their providers (Shim 2010). Members of the lower castes often try to learn English but may not have social and economic resources (Bennett et al. 2008; Patel 2012). The lower castes experience stressors such as encountering racist language and physical violence

(Bennett et al. 2008; Patel 2012; Subedi 2016a). Research conducted by Hatzenbuehler et al. (2013) indicates that experiences with stigma diminish an individual's psychological resources, fostering maladaptive coping mechanisms such as smoking or problem drinking. Encounters with stigma are associated with being in worse health because individuals experience stressors, which further exacerbates existing health conditions

(Hatzenbuehler et al. 2013; Phelan et al. 2014).

Caste Resources and Coping

Research conducted by Link and Phelan (1995) illustrates that social conditions function as pathways that influence health outcomes. Individuals who have access to resources such as knowledge, prestige, power, and wealth are less likely to develop physical and mental health conditions (Hatzenbuehler et al. 2013; Link and Phelan 1995).

More privileged individuals will have an easier time accessing services because of their access to knowledge, resources, and prior education (Link and Phelan 1995). On the other hand, lower castes often lack the more privileged castes' social and economic resources

(Bennett et al. 2008; Patel 2012). For instance, individuals belonging to lower castes seldom received formal education and were often illiterate in Nepali and English (Furr

2005). Bennett et al. (2008) have found that lower castes are less likely to seek treatment for medical conditions and cannot understand public health information due to their lack of resources.

Individuals belonging to the lower castes also encountered marginalization through policies enacted by the Bhutanese government. For instance, members of the

Shudra caste were banned from completing an education and are seldom exposed to the

English language (Bennett et al. 2008; Benson et al. 2012; Kohrt et al. 2009). Inability to speak English restricts resettled refugees' ability to find meaningful employment and impairs their ability to form meaningful relationships with other people (Ager and Strang

2008). Disruptions to employment constitute a significant stressor and weaken access to resources (Link et al. 2008; Link and Phelan 1995). Individuals who struggle to learn the

English language report that they encounter difficulties building relationships with others

(Ager and Strang 2008; Benson et al. 2012; Strang and Ager 2010). Numerous studies have found that individuals who lack social support from others are at higher risks for developing depressive symptoms (Hatzenbuehler et al. 2013; Thoits 1995).

Several studies indicate that the caste system influenced the resettlement process

(Dutton 2011; Ott 2013). A report conducted by Ott (2013), has found that higher caste members were resettled into western societies sooner than members of lower castes, found employment, and were often placed in more affluent neighborhoods. Patel (2012) indicates that members of subordinate castes frequently reported that their marginalized social status remains a source of distress even when resettled into a new country. The

56 lower castes have fewer resources to navigate their new communities (Ott 2013; Patel

2012). Several studies also indicate that the Bhutanese community members frequently subscribe to the same codes (Muluki Ain) that shaped social interactions in their country of origin (Dutton 2011; Ott 2013; Patel 2012). For instance, marriages between different castes are viewed as inappropriate and remain associated with feelings of stress and anxiety (Dutton 2011; Patel 2012). According to Link and Phelan (1995), health disparities will persist over time regardless of changes in resources or intervening mechanisms.

Mental Health Consequences

During their time in the camps, Bhutanese refugees reported feelings of anxiety and often suffered from ulcers (CDC 2014; Patel 2012). According to Dutton (2011), the development of these symptoms was associated with rapid departure from Bhutan and exposure to traumatic life events. Prior research also suggests that Bhutanese women are more likely to develop depressive symptoms than men (Kohrt et al. 2012; Luitel et al.

2013; Vonnahme et al. 2015). These symptoms are associated with encounters with sexual violence and human trafficking in refugee camps (Lundström and den Uyl 2010;

Vonnahme et al. 2015). There is substantial evidence that refugees who the Bhutanese government tortured are much more likely to develop psychiatric conditions including depressive symptoms, stress disorders, and experience physical pain (Kohrt et al. 2012;

Luitel et al. 2013; Van Ommeren et al. 2001). Further Bhutanese/Nepali refugees have increasingly turned to drugs and alcohol as a coping mechanism for acculturation stress

(Luitel et al. 2013; Subedi et al. 2015). Indeed, numerous studies have found the alcohol

57 is easier for resettled community members to access when resettled into western societies, which further exacerbates problem drinking (Luitel et al. 2013).

Several studies suggest that these mental health conditions are worsened by the resettlement process, remain untreated, and sometimes result in suicide (Adhikari et al.

2015; Ao et al. 2012; Kohrt et al. 2009). There is a dramatic increase in suicides committed upon resettlement, and Bhutanese refugees have a suicide rate of 20.3 per

1,000 people, which is almost twice the national average of 12.4/1000 (Hagaman et al.

2016). Further Bhutanese refugees are more likely than other refugee groups to commit suicide and are also less likely to seek mental health treatment (Ao et al. 2012; Hagaman et al. 2016; Kohrt et al. 2009). In several reports, Bhutanese refugees often report that they know a family member or friend who has committed suicide due to trauma associated with migration (Adhikari et al. 2015; Ao et al. 2012; Hagaman et al. 2016).

According to Hagaman (2016), working-aged men who cannot find employment are at increased risk of committing suicide. Furthermore, individuals who have lost connections to family members or lack social ties also are at high risk for suicide (Ao et al. 2012).

The Bhutanese have a different conceptualization of mental health than the dominant perspective in western forms of medicine. For example, members of the

Bhutanese community often describe mental illness as a force external to the individual, which also influences family members (Dutton 2011). There is substantial evidence that members of the Bhutanese community perceive their mental health as interconnected with other people (Shannon et al. 2015). Several studies further indicate that mental illness in the Bhutanese community is defined as feelings of sadness that prevent individuals from forming relationships with others (Benson et al. 2012; Patel 2012;

Shannon et al. 2015). Further, the lower castes often use traditional healers to treat mental health conditions rather than a counselor or doctor (Dutton 2011). Culturally competent counseling services were often not available in the camps, and there were seldom resources in place for any type of mental health treatment (Dutton 2011).

Theoretical Framework

This project aims to explain how caste shapes the resettlement experiences of

Bhutanese/Nepali refugees and health outcomes. I argue that individuals who possess more cultural health capital will experience better health outcomes than people who have less cultural health capital. I would also expect some individuals to cling to traditions associated with their host society as a coping mechanism. These behaviors can become problematic if Bhutanese/Nepali refugees practice traditions associated with alcohol consumption (Dhital et al. 2001) or do not seek medical care (Bennett et al. 2008). These behaviors are likely more common for lower castes who may experience more acculturation stress upon resettlement. In general, this project will offer some insight into how the caste system continues to shape health outcomes upon resettlement.

Cultural Health Health Outcomes Capital Acculturation

Stress

Caste Status

Figure 1: Theoretical Model of Influences on Health Outcomes

I anticipate that higher caste individuals who have access to more cultural health capital8 will likely encounter fewer barriers to care and have better health outcomes.

Indeed, members of higher castes likely have an easier time accessing medical services because they are more likely to be educated and speak English (Gellner 2007; Subedi

2016a). Further, members of lower castes were marginalized in their society of origin through government policies, which restricted access to education. There is substantial evidence that members of the lower castes encountered discrimination during their time in Bhutan and in the camps (Dutton 2011; Patel 2012). For example, members of the higher castes enacted policies preventing members of the lower castes from getting an education and accessing medical care (Bennett et al. 2008; Subedi 2016b). According to

Patel (2012), the lower castes also encountered open discrimination from the upper castes during their time living in refugee camps.

I would also expect that members of the lower castes would experience more feelings of acculturation stress than the upper castes, which would foster worse health outcomes. The stressors of being in a lower caste are exacerbated during forcible displacement from Bhutan and experiences with human rights violations (Dutton 2011;

Shrestha 2011). Further Bhutanese refugees encountered further stress upon their forced migration into camps as well as their resettlement to northeast Ohio. Members of the lower castes have less cultural health capital and fewer resources to cope with acculturation stressors than the upper castes. I anticipate that this would lead to adverse health outcomes for members of the lower castes. Scudder and Colson (1982) also remind

8 As noted in the next chapter members of the upper castes often worked in more stable and prestigious occupations. On the other hand, members of the lower castes are frequently employed in the service sector. There is substantial evidence that work in low status occupations is associated with additional stress, which likely worsen health outcomes (Aneshensel 1992; Pearlin et al. 1981; Thoits 1995).

60 us that members of forcibly displaced populations experiencing acculturation stress cling to the traditions of their society of origin. For example, to cope with additional stressors, the lower castes may practice religious traditions associated with their caste upon resettlement.

The current study expands on the stratification and health literature by exploring stressors and life strains associated with refugee status. Data was collected from a larger project called the Bhutanese Refugee Substance Abuse Study (BRSAP). The project was led by Dr. Marnie Watson and carried out by a research team that collaborated with the

International Institute of Akron. The larger study focused on getting individuals into treatment for alcohol-related conditions, but the data can still address concerns related to the caste system. This study also contributes to the literature on fundamental causes by shedding light on how the caste system influences mental health. Two research questions will be addressed using 100 in-depth interviews conducted with members of the

Bhutanese community. First, how do sources of stress and inequalities tied to the

Bhutanese caste system shape refugees' resettlement experiences in the United States?

Second, what are the consequences of this caste system for refugees' health and wellbeing, specifically their mental health and alcohol use?

METHODS

Qualitative data was initially collected during the summer of 2017 as a collaborative project between the University of Akron9 and The International Institute of

9 The project was led by Dr. Marnie Watson, who now works at Missouri State. Radha Adhikari managed social services at IIA and helped advise the research project. Five research assistants from the University of Akron: Jimmy Carter, Nuha Alshabani, Julian Curet, Vyshu Ramini, and myself assisted with the project. Our team also had a cultural broker, Santa Gajmere, hired by IIA to work as our interpreter and ensure we respected culture and traditions. Santa also assisted us with interpreting interviews for participants who did

Akron (IIA). Our data was focused on studying problem drinking in the

Bhutanese/Nepali community. Semi-structured interviews were conducted with 100 members of the Bhutanese/Nepali community. Interviews covered a range of topics including access to health services, substance abuse, and potential community-based solutions to overcome barriers to using health providers. The interviews also covered the resettlement process and participant caste.

In this chapter, I focus on the narratives of three participants, and my analysis is intended to illuminate the lived experiences of my participants. As noted by Franzosi

(1998), narrative approaches allow sociologists to analyze the relationships between participants and social structures. I selected three interviews, which are reflective of the entire sample and illuminate the lives of my participants. Further, these narratives complement subsequent chapters, which take a more holistic approach to understand health inequalities and the resettlement experiences of Bhutanese/Nepali refugees.

There was a total of 20 local providers who worked directly with the

Bhutanese/Nepali community who were interviewed, as well as two focus groups with seven providers in each. Providers worked for a range of facilities including community health centers, mental health clinics, and the local police department. Providers were asked a series of questions about the services that they provide to the community, behaviors related to problem drinking, and perceptions of how to treat substance abuse.

not speak English, recruiting people to participate in the project, going over the informed consent form, and providing a debriefing for participants.

Sampling Methods and Coding Procedures

Our team utilized snowball sampling, which helps researchers identify subgroups that participants belong to and is also helpful for building rapport with participants

(Heckathorn 2011; Sadler et al. 2010). Theoretical sampling was also employed in the original study to ensure each caste was represented in our data and other subgroups from the Bhutanese community (Corbin and Strauss 1990; Glaser and Holton 1967).

Theoretical sampling ensured that participants were represented across age, caste, religion, and sex. The first five interviews were coded by the research team members using open coding to identify the preliminary themes in the data. After coding the initial interviews, our team met to develop a codebook, and discrepancies in codes were discussed during proceeding meetings. Finally, we used focused coding to assess the most dominant themes from the interviews, which were carefully inspected by the research team10.

Community Member Characteristics

The largest caste was the Vaisya (30 percent), followed by the Chattriya (24 percent), Brahmin (23 percent), and Shudra (23 percent). The lower castes (Vaisya and

Shudra) composed just over half of the sample (53 percent), and the higher castes

(Brahmin and Chattriya) consisted of the remaining 47 percent11. Regarding religion,

10 This project also met the guidelines presented by the University of Akron's IRB board. Our cultural broker assisted the participants with understanding the written informed consent form and debriefing. At any time, community members who completed an interview could contact the research team and ask for their information to be destroyed.

11 Members of the Bhutanese community subscribe to the caste system associated with their society of origin. The highest castes are the Brahmin and Chhatriya who are scholars, priests, and administrators

63 most participants practiced Hinduism (34 percent) or Christianity (30 percent). Almost a quarter of the respondents believed in Kirat (23 percent), and 13 percent were Buddhist.

Participants were 40 years old. The oldest participant was 70 years old, and the youngest was 19. Men consisted of 55 percent of the sample, and women were 45 percent.

Table 6: Summary Statistics Demographic Mean/Percent Gender Male 55% Female 45% Age 40 Religion Christian 30% Hindu 34% Kirat 23% Buddhist 13% Caste Brahmin 23% Chhatriya 24% Vaisya 30% Shudra 23% Total 100%

Provider Characteristics

Women composed 60 percent of the sample, and men formed the other 40 percent. Seven employees worked for social services agencies that offered community members a variety of services related to healthcare, employment, and housing. Six providers worked for community health centers. Local resettlement agencies employed four providers. Two providers worked at behavioral health centers or mental health clinics. There was only one participant who worked for the local police department and held a position related to working with the Bhutanese/Nepali community.

(Gellner 2007). Lower castes are composed of the Vaisya and Shudra who are laborers, servants, artisans, and merchants (Gellner 2007).

Table 7: Provider Characteristics Demographic Frequency Percent Organization Type Behavioral Health Services 2 10% Community Health Center 6 30% Law Enforcement 1 5% Resettlement Agency 4 20% Social Services 7 35% Gender Male 8 40% Female 12 60%

PROVIDER RESULTS

This chapter aims to illuminate how the caste system functions as a fundamental cause of mental health and shapes health inequalities. However, I have included this section to contextualize the Bhutanese/Nepali refugees' experiences, which are likely exacerbated by caste status. Interviews conducted with 20 providers further accentuate the mental health concerns and demonstrate that substance abuse is a community problem. This segment of the chapter presents vital results from provider interviews, and

I have framed these findings using Bloomberg and Volpe's (2008) approach to reporting data. I identify two major themes.

Finding One. All providers (20 of 20) reported that alcohol and substance abuse caused problems in the Bhutanese/Nepali community.

The main finding of provider interviews is that alcohol and substance abuse fosters problems in the Bhutanese/Nepali community. This finding is important because all 20 of our providers discussed the problems alcohol causes in the Bhutanese/Nepali

65 community. Respondents suggested that alcohol is responsible for domestic violence, drinking and driving, and exacerbates acculturation stress. Our providers explain:

There are significant problems like sometimes, they have like a misunderstanding in the families. Like sometimes husband and wife, they have misunderstanding. Like, sometimes wife doesn’t like her husband drinking all the time. Maybe sometimes they fight. And sometimes, like many people, they have an accident, like drinking and driving. (Male, resettlement agency)

I mean, certainly, alcohol isn’t a bad thing when it's not being abused. But I think

the issue is amongst the refugees is. . . it's-it's being abused. Like you know their

intoxicated a lot. Um and they're not able to function. . . or work. . . or deal with. .

. or be in society. (Male, law enforcement).

Further, one provider explained that alcohol was a problem in the community, but there are some limitations in treating substance abuse. She explains:

I know that there I guess this is the way I look at it. I'm, I don't know how

prevalent it is because I only know what comes in my door. I know that there's a

problem. And when I say that, really, what I'm saying is that I know that there's

people that have problems with alcohol, and there's not a lot of solution for it.

Therefore, I know there's a problem… (Female, Behavioral Health Services)

Two respondents (3 of 20) reported that the abuse of other substances such as tobacco, marijuana, or drug use also caused problems. Most providers were concerned that teenagers and other youth are using drugs in addition to alcohol. Participants reported:

I mean, the huffing and the inhalants just keep coming up in that community. It

seems like that's, um, you know, and I don't know why that is… I think maybe

part of the reason, like one thing I've heard is like… I think that's something that

was available in the refugee camps… And so maybe that's just something that

they know and it's like a quick and easy thing, just like in some neighborhoods,

like you know, meth is bigger, and some schools you know… Different drugs are

just in different pockets and in different neighborhoods and things… So, I don't

know why that seems like what they're coming in with. (Female, Community

Health Center).

I didn't see they use marijuana back in Nepal and refugee camps or in Bhutan… But here I think young kids… teenaged kids get started… I could see that's the problem. Yeah, only I saw like only adults use it…. Back in Nepal, or refugee camp… Bhutan… Here, everybody started to use it as they can access easily (Female, Social Services). Finding Two: A majority of providers 17 of 20 indicated that depressive symptoms and suicide were also problems in the Bhutanese/Nepali community.

A majority of the providers indicated that depressive symptoms were commonplace in the Bhutanese/Nepali community. Several indicated that depressive symptoms developed because of acculturation stressors such as finding work, learning

English, and being separated from family members. Others mentioned that community members were experiencing psychosomatic symptoms (Shannon et al. 2015). Participants expressed their concerns about mental health:

So, for mental health, it's a mixture of things. For men, I see a lot of depression

around. Not… around kind of losing their sense of who they are, you know, not…

not being able to work not being able to provide for their families. Sometimes

there's a history of torture or some kind of trauma but… But not always… I'd say

with the women I see a lot more somatic health issues. Probably a lot of them

stem from depression or stress. The other thing I see with the community is the

language barrier, I see a lot of anxiety with trying to use their English that they do

know or being in situations where they're not sure how to respond or how to

communicate. (Female, Behavioral Health Services)

And related to age. I see more somatic symptoms in this occasion so compared to

other populations so when symptoms are very severe, it's like you know

constantly you know, talk about this you know, our pains in their body, which

cannot really be helped by the medication and providers like sometimes like a told

me.. It is probably because of like an… Um… the only environmental

malnutrition and they are… Not really they just like… Not really got sufficient

care since childhood. So, like this is like the body is kind of like you know built

that way… I Their body age is compared to other Western population is much

older. And you know, you know the aging processes is likeness much faster…

than our… Compared to other populations. So, like, although like the

considerably young to our Western population, they already begin to have

symptoms that can be seen in older generations. (Male, Social Service Provider)

People are depressed because they are lonely. A lot is because of the political situation; their families got separated. So many of them are in another state… Another country or they're back home [in Nepal]. So, there are a lot of people who are depressed due to that. (Male, Resettlement Agency)

More than half of respondents (14 of 20) also mentioned that suicide was commonplace within the Bhutanese/Nepali community. One provider who worked in law enforcement stated, "With the adult men there are suicides. The ones that alcohol wasn't enough, and they just think that they can't adjust. They're using suicide as a last resort".

The officer's response is consistent with literature finding that Bhutanese men are at an

68 increased risk for committing suicide (Dutton 2011; Subedi et al. 2015). Another provider working at a social services agency echoed the sentiment but believed religious beliefs influence suicide. However, she did not mention alcohol abuse causing the behaviors during our focus group. She explains:

I think, culturally [about suicide], and this, you know, it's just a theory of the idea of fatalism, and like, this is determining my future. And because of this, then I am hopeless. And I… I… I think that could be part of it. Because we see things like, oh, if someone is diagnosed with like diabetes, and thinking like, Oh, no, now I have this. And that's the end of my life. Or like someone is unable to read or understand, like, a document… a medical document and see a large sum of money… And they think, Oh my gosh, now I owe all this money… It's hopeless and immediately going to that like the There's no hope. I don't know if it's because maybe where people come from. They don't have a lot of resources or because there's a cultural sense of like fatalism. (Female, Social Services Provider).

One respondent working at a resettlement agency suggested that members of the

Bhutanese/Community have a much higher rate of suicide because there is a stigma attached to discussing mental health problems. He stated:

We really had high very, very high suicide rate. That's the main issue. It's just

because of stigma that they have that they don't really talk about. The problems

they don't really share any problems with other people because and… also I just

want to since it's my community our people are more judgmental, and that's also

the reason why they don't share information with other people. And they don't

want to be like what you call below everyone else… they want to be… they don't

want to share their weakness.

In sum, providers reported that depressive symptoms continued to shape the experiences of resettled Bhutanese/Nepali.

COMMUNITY MEMBER RESULTS

Interviews conducted with community members demonstrate that the caste system shapes health outcomes upon resettlement into Northeast Ohio following life in the camps. On the one hand, the lower castes may be exposed to a range of risk factors and experience several disease outcomes. On the other hand, members of higher castes may experience countervailing mechanisms, which work against their wellbeing. Accounts from resettled community members also reveal that Nepali/Bhutanese may cling to traditions such as healing rituals or caste positions. I focus on three narratives constructed from community members, which demonstrate their experiences with acculturation stress and shed light on caste as a fundamental cause of physical and mental health. As noted in the methods section, I selected these participants because they were representative of the social inequalities perpetuated by the caste system and were reflective of the rest of the sample. In general, providers demonstrate that substance abuse and concerns related to mental health remain a significant problem in the Bhutanese/Nepali community.

As noted in the second chapter, the members of the Bhutanese of Nepali descent still subscribe to the legal code Muluki Ain, which was initially intended to cement

Nepal's reputation as the world's only Hindu monarchy (Gurung 1970). The Muluki Ain legal system regulated Nepali marriage, work and occupations, religious ceremonies, and codified discrimination (Gurung 1970; Levine 1987). The code was expected to benefit the ethnic (hill tribes) and the Hindu religious majority (Cox 1970; Gurung 1970; Levine

1987). Muluki Ain has been revised several times to temper discriminatory policies, which marginalize members of the lower castes. In 1963, many of the inequitable policies against the lower castes have been abolished, and by 1990 Nepal asserted that they are an

70 equal society. However, the caste system continues to shape the lives of Bhutanese of

Nepali descent, and caste-based discrimination still takes place. Patel (2012) found that members of the lower castes could not consume water from the same sources as members of the upper castes in refugee camps. Therefore, it is essential to acknowledge the caste system influences religious beliefs and culture.

Table 8: Participant Pseudonyms Pseudonyms Gender Age Caste Religion Tika Female 45 Brahmin Kirat Prakesh Male 45 Shudra Hindu Sarah Female 19 Shudra Hindu Bhim Male 31 Brahmin Christian

TIKA AND PRAKESH: SEEKING TREATMENT IN NEPAL

Tika is a member of the Brahmin caste, and her husband, Prakesh, belongs to the

Shudra caste. Their marriage is forbidden under the Nepali legal system, and the couple likely encounters stigma from others in the community. Our interview was conducted in

Nepali, but I could sense the friction in their relationship. At times they argued with each other, and there were some portions of the interview our culture broker seemed reluctant to translate. The couple's social positions influenced their ability to find care for their sick daughter. On the one hand, as a member of the Brahmin caste, Tika likely has more cultural health capital than her husband and stressed that her daughter needed to be treated by a medical professional.

On the other hand, her husband was a member of the Shudra caste. There is also substantial evidence that members of the lower castes are often denied participation in the healthcare system and are less likely to seek medical treatment than (Lamsal 2012).

Scholarship conducted by Subba (2009) further demonstrates that members of lower

71 castes are more likely to seek medical treatment through traditional medicine such as healers.

Tika and Prakesh12 had been expelled from Bhutan and had been resettled in

Nepal in the early 1990s. They first started drinking in Nepal when their daughter,

Anamika, began to have intense physical pain symptoms. The couple noticed that the daughter started walking with hunchback when she tried to walk, and her condition impaired her ability to run. When Tika described Anamika's back, she noted: "My daughter was two years old when she told me she was in pain. Part of her muscles shifted and never went back". The couple also noticed that one of their daughter's legs was much shorter than the other, which exacerbated Anamika's mobility issues. By the age of eight,

Anamika began having epileptic seizures, which further strained the couple. When describing his daughter's episodes, Prakesh explained that "[Anamika] would fall down and just show the whites of her eyes".

As a member of the Shudra caste, Prakesh believed firmly that Anamika's health problems were rooted in Nepali/Bhutanese traditions rather than medicine. At first, he thought that his daughter had a poor diet and began cooking traditional meals for his daughter. These dishes contained healing herbs such as ginger or honey. Despite

Prakesh's efforts, Anamika still complained of pain and continued to have seizures.

Prakesh started taking Anamika to see a traditional Hindu healer called a jumping doctor to ease his daughter's suffering. Prakesh began to believe that Anamika's condition had a divine cause. During our interview, he explained:

Half of My daughter's body was totally different from the other… It shrunk it was smaller… It became narrow… In Hinduism, there are gods named Shiva and Lakshmi. So, Shiva is one part of the god, and Lakshmi is the other part of the

12 All Community member names are pseudonyms.

god… There is a statue of both of them coming together, half part male or female. My daughter became just like that statue. One part smaller and one part bigger…

The jumping doctor confirmed Prakesh's suspicions that Anamika's condition was a curse from the Hindu snake god Nag. The traditional healer instructed that the family should not seek medical intervention for Anamika's condition. Instead, the jumping doctor believed he could treat Anamika by chanting Hindu prayers and directed Prakesh to continue his use of traditional medicines.

Tension flared between the couple when Tika, a brahmin, believed that a medical doctor would better be equipped to treat their daughter than a traditional healer. Both partners were members of different castes, which likely produced tension in their marriage. Prakesh reasoned that "If we take our daughter to a [medical] doctor as soon as they inject her with medication, she will eventually die". Decades ago, Tika lost her mother during an operation, and Prakesh feared that a medical procedure could also cost

Anamika her life. Despite her loss, Tika still believed that a medical doctor could treat

Anamika's condition. She defended her position "I argued my daughter would get better if we go to the doctor… I kept on saying it. Most of the relatives and family members tried convincing Prakesh". Due to this friction, the couple began having intense arguments with each other. During the interview, the couple suggested their fights would often become physically violent.

Desperate for help, Tika took her daughter to local hospitals in Dharan and

Mechi. She did not have money to pay the fee to admit her daughter to either of the hospitals. Fortunately, her friends loaned her the money, and Anamika was admitted to the hospital in Dharan. To further help cover her daughter's expenses, Tika started an illegal business selling traditional alcohol (raksi) in the refugee camps. Tika kept

Anamika at the hospital for nearly a year, but she often struggled to pay her daughter's medical expenses. During this time, Anamika received surgery to correct her back deformity and received treatment for her seizures. For over a month, Anamika could not walk independently, and her parents often resorted to carrying her around their home.

Tika and Prakesh also needed to assist their daughter with toileting and bathing. Tika explained that her daughter could not use the crutches provided to them by the hospital, and she worked to rehabilitate Anamika on her own time. Tika reflects: "After three months of exercise, she started walking by herself… It took exactly three months to let my hands go from her hand".

In 2013, Tika and Prakesh were resettled directly in Northeast Ohio, but Anamika moved to South Dakota. According to Prakesh: "She got married in South Dakota! She's perfect! Sometimes she complains about the pain, but everything's good". Anamika still receives physical therapy for her back and receives medication to assist with her epilepsy.

Further, her husband works in a hospital and helps Anamika navigate the healthcare system. Prakesh also acknowledges that he was wrong to push his family towards seeking traditional treatments. He explains: " Many people have a false belief in the traditional way. This is the modern world now… That's why we still took Anamika to the hospital for surgery. I think it's better now". During our interview, tensions between the couple were still evident, and both partners accused the other of continuing to drink too much alcohol. On the one hand, Tika claimed, "My husband always drinks in somebody else's house… My friend's house… or family house… Me I drink alone". On the other hand,

Prakesh argued: "If she drinks, she drinks a lot!". In general, these respondents

74 demonstrate how the caste system shapes marriage and health inequalities in the

Bhutanese/Nepali community.

SARAH: ACCULTURATION STRESSORS

Sarah and her family are members of the Shudra caste who work in the service sector. Her mother worked as a domestic laborer during her time in Bhutan and worked as a housekeeper upon resettlement. Sarah's father was employed as a military security guard and suffered from several injuries due to his work in a precarious occupation. Link and Phelan (1995) remind us that fundamental causes have multiple risk factors and disease outcomes, which is reflected through the father's experience with illness. Sarah's father avoided seeking medical treatment for his disabilities and began to self-medicate with alcohol. As a member of the Shudra caste, he began drinking at Hindu religious ceremonies, which is normative for his caste. Sarah asserts that he began to drink to cope with the new sources of acculturation stress he encountered upon resettlement. The resettlement process also impacted Sarah's health; she reported feelings of social isolation and struggled to build relationships with others -- upon resettlement, she did not speak

English.

Sarah was just 13 years old when her family was resettled in Trenton, New Jersey, with a small Bhutanese/Nepali Community. She explained that only a dozen families lived in the area, and local agencies often struggled to provide the community with adequate care. Sarah claimed: "We had an agency in Trenton, but no Nepalis worked there… people who came to our house and helped us… They only had one Nepali interpreter, and he had to speak everywhere". During her time in school, Sarah reported that she often felt lonely and isolated from other people. She explained:

When I was young, it’s just… I had no friends… There were no Nepali people. I was alone, and I used to cry when I went to school. Everybody looked so different. So, I did not know who to talk with, and everything about Trenton was different.

Sarah did feel her time in Trenton helped her master the English language because she was forced to speak in school. However, her parents still encounter difficulties speaking

English and accessing resources in their community. According to Sarah: "I still help them talk on the phone. Like if they get calls from offices or insurance and all that. I talk for them".

Sarah's family decided to move to Akron because it had a much larger

Bhutanese/Nepali community, and her family knew other community members. She explains: "When I came to Akron, I have friends. And it just feels more, you know, safe… I feel like I belong here". Sarah also believed that resettlement agencies were better equipped to assist community members than agencies in Trenton. She explained:

"We have a lot of interpreters here that help. Like if you got to go to hospital… and like they provide transportation too". Her family also took advantage of educational programming and courses offered by local resettlement agencies. However, Sarah acknowledged that many of these programs had been slashed due to budget cuts at the international institutes. Many local agencies have begun to lay off interpreters and caseworkers, which further harms resettlement programs. Sarah explains: "People really get mad because nobody works at the Institute who can help… Like all the interpreters don't work here anymore".

Although Sarah's parents were able to find work in Northeast Ohio with the help of their friends and others in the community. Like many members of the Shudra caste, both of Sarah's parents found employment working in the service sector. Her mother

76 worked as a housekeeper, and her father worked at a plant that manufactures skin care products. Both parents were employed in entry-level positions, which lacked benefits and paid just above minimum wage. Sarah told us her parents needed these jobs to ensure that the family could make ends meet. In Bhutan, Sarah's mother worked as a housekeeper and was happy that she could find work related to her area of expertise upon resettlement.

However, her father used to be a military security guard and felt that his new job was losing his previous status. He continues to follow Bhutanese/Nepali social norms, working long hours because he believes that he needs to take care of Sarah and his wife.

Sarah's father was also wounded during his time in the military and suffered from a missing eye and hand. Sarah helped her father apply for disability benefits, but their application was denied. Her father's company reported that he could do all the job's essential functions and did not need accommodations. Sarah told her father to stay home from work if his disability prevented him from working. However, her father feared being fired due to having many attendance points. Sarah's father told her: "I still want to work until I feel like I cannot do it. Right now, it’s a lot of pressure, but I want to do it a little more". Her family's lack of benefits was also a concern for Sarah. She explained:

"Although my dad has high blood pressure all the time. We don’t go to doctors unless we get really sick… We just do not go to the doctor". Due to their lack of resources, Sarah also reported her father and other members of the family were unable to get medication for their health conditions.

To cope with employment and physical health stressors, Sarah's father began to engage in problem drinking. She reported that her father started heavily drinking when conducting traditional Hindu rituals where participants consumed alcohol. Her father

77 gradually began to consume larger amounts of alcohol to cope with stressors associated with work. Sarah explains:

Well, he’s not Christian. He’s Hindu… I don’t know… He’s Hindu just because

we’re Nepali. But he does not do like prayers and all those things. Drinking is a

family tradition. It’s just a drink, you know. And like when we have a culture day

and all that like, you know, just all family sit together and have fun. I mean they

do not drink a lot during the celebrations. Then my dad started to drink… All the

pressure, you know.

Sarah's comment suggests that her father may have begun drinking at religious ceremonies but quickly adopted substance abuse as a coping mechanism. Scudder and

Colson (1982) remind us that forcibly displaced populations may cling to traditions associated with their society of origin to cope with stressful life events. Indeed, members of the lower castes often consumed alcohol during religious ceremonies, which indicates alcohol use is frequently perceived as normative for people belonging to the Shudra and

Vaisya castes (Dhital et al. 2001; Subedi 2011).

Sarah felt that her father's experiences with acculturation stress put pressure on her and her mother. She recalled one episode where her father screamed: "You're not my daughter" while intoxicated. Sarah left home to stay with her uncle for a few weeks before returning home. She noted that her father apologized for his actions: "He stopped drinking for a few weeks, but then he just starts again". Sarah explained that her parents had started fighting verbally, which never used to happen when the family was staying in

Nepal and Bhutan. She believed that her household was always supportive, but all the

78 family problems began when her father started drinking. When asked how she felt about her father's drinking problem, Sarah explained:

It just makes me feel so sad and emotional. I don’t want my dad to do that. I understand he has a lot of pressure. But it just, I don’t think it’s the way to get through that, you know, get through work. It’s just, I mean what, ok he home, forget everything. I get it. But um, he just has to get up the next morning and go to work again. Like it’s, it’s not worth it.

Despite the problems at home, Sarah is optimistic that she has the resources to attend college and find a job working as an early childhood educator. Sarah graduated from high school in 2016 and has already earned a scholarship to attend a local university.

BHIM: CULTURAL HEALTH CAPITAL

Bhim is a member of the highest caste (Brahmin) who are also the most privileged in Bhutan and Nepal. Our interview with Bhim was conducted in English. Our cultural broker just reviewed the informed consent form with Bhim rather than interpret the entire interview. He was also able to rebuild his social networks and had several friends outside of the Bhutanese/Nepali community. Indeed, social networks provide a buffer against the development of depressive symptoms (Pearlin et al. 1981; Thoits 1995). Bhim's background also likely helped him find a stable position at a food supply company. He worked 40 hours a week and received medical benefits. His status helped him avoid many of the work-related stressors Sarah's father encountered, who often worked long hours without medical coverage. Bhim also had the cultural health capital to advocate for the treatment of his family members. He needed to provide care for his aging mother and sister with a disability. On his own initiative, he reached out to medical providers to find care for his family.

Bhim and his family came directly to Akron in 2014 and resettled into what he considered a nice neighborhood. He learned English upon resettlement, which helped him find stable employment, and connect with his neighbors. Bhim works at a food supply company in a full-time position and has been with the company for more than three years.

However, his career sometimes prevented him from taking care of his elderly mothers, who developed spells of severe pain in her stomach and eyes. Bhim's ability to speak

English helped him develop friendships with people outside of the Nepali/Bhutanese community. He explains: "One of my neighbors is like a father to me; he looks after my house when I am not home and takes care of my sick mom… I love my neighbors".

Bhim's neighbors also visited his mother when she spent several weeks in the hospital due to an episode of pain in her stomach.

When Bhim's mother began feeling sick, he tried to reach out to local social service agencies for help. He also had a sister with a disability who needed to be cared for by a family member. Bhim tried calling social services at several local agencies to find medical care for his family members, but many of these agencies were understaffed.

According to Bhim, many of the organizations he called told him: "We don't have time to talk with you. Call again tomorrow". Frustrated, Bhim decided to take matters into his own hands and started making direct calls to doctors and filed for benefits without a social services agency. He explains:

I started following up by myself and started taking her and my sister to various doctors. I filed for social security and SSI by myself. I was successful, and they could get SSI. My mother and sister also needed a caregiver, and I had to spend extra time taking care of them… But my sister was not approved as a caregiver. I tried going to another agency for help with getting my sister's care. They said, 'Ok we can approve your application within ten days and then we will follow up'. It has been more than ten business days and my sister still has not been approved.

Although Bhim had success getting SSI, he made these appointments years ago and still encounters barriers to getting care for his mother and sister. For example, his mother needs to take dozens of medications to help keep her health conditions in check but cannot afford many of them. After the interview, Santa, the interpreter, worked with

Bhim to find medical coverage for his mother.

Bhim also received some help from the International Institute, who helped his mother schedule a doctor's appointment and provided his mother with a Nepali interpreter.

I do not think some of the interpreters at the institute are qualified… They let them to go to with my mom interpret. When I was new to Akron, I went with my mom and the interpreter to the doctor's office. This was when she first started having stomach pain, and I described her problem to the doctor. The interpreter translated her symptoms in a different way. My mom was asking about pain in her bones, but they were only talking about her stomach pain.

Bhim was frustrated by the interpreter's inability to describe his mother's medical symptoms accurately. He asked the doctor: "Can I interpret for my mom? I can do it! I know my mom better than this guy".

In addition to his family's medical problems, Bhim became concerned about his son attending one of Akron's high schools. His son felt unsafe attending the local high school due to physical fighting among students, bullying, and drug use. Bhim was horrified by one video he saw of local Nepali/Bhutanese teenagers. He explained, "Once there was an incident where I saw son’s friends smoking and using drugs… I thought my son was there". Indeed, Bhim felt that his son's environment added to many of the stressors he encountered upon resettlement. He explained:

"My son's English has improved because of his friends, but I am worried about him. If his friends are a bad influence, he might embrace bad behaviors --bad

roots. Sometimes I lose sleep over it and have bad dreams. I know I am overthinking things, but my son wants to switch schools".

Bhim believed that Akron's schools did nothing to prevent the problems with students engaging in drinking and doing drugs. He explained, "Parents think their kids are in school, but they are not… Maybe they are outside the school doing drugs… Our high school and police are careless". Bhim is considering moving to a more affluent suburb adjacent to Akron just to get his son into another school district, "I think they have better schools and more opportunities for college".

DISCUSSION

The narrative presented in this chapter illustrates that members of the upper castes often have access to more cultural health capital than the lower castes. Tika reached out to her friends for a loan and started a business in the camps to afford medical care for her daughter. Tika took her daughter to multiple hospitals for treatment, and she pushed doctors to get her daughter into surgery. Likewise, Bhim could speak English and had the resources he needed to navigate his host society. He felt confident taking matters into his own hands and felt comfortable interacting with medical professionals and social service providers. He reached out to multiple agencies to ensure that his family members were cared for by medical professionals. Gengler (2014) reminds us that individuals with more cultural health capital advocate for their own medical treatment than people who have less capital. When people with less cultural health capital do get treatment, they seldom push medical professionals for treatment and often follow medical advice without question (Gengler 2014). This behavior is reflected through Prakesh administering the traditional remedies recommended by the jumping doctor. Even when the treatments did not appear to be working, he continued to practice the shaman's rituals.

Another finding from the narratives is that members of the lower castes likely experience more acculturation stressors and may cling to the caste system as a coping mechanism. Indeed, Scudder and Colson (1982) have found that individuals experiencing more acculturation stress are more likely to cling to traditions practiced in their host society. Sarah's father started drinking in order to practice the Hindu rituals associated with his caste. Dhital (2001) reminds us that it is normative for members of the lower castes to consume alcohol as a part of their rituals. However, his drinking quickly spiraled out of control, and he started abusing alcohol regularly. His drinking behaviors produced additional tension in his marriage and caused friction with his daughter. When initially resettled, Sarah reported depressive symptoms because she struggled to build relationships with her peers, but she quickly learned English during her time in school.

These narratives suggest that the caste system operates as a fundamental cause upon resettlement into Northeast Ohio. According to Link and Phelan (1995), a fundamental cause has multiple risk factors, which lead to the development of mental illness. On the one hand, Sarah's father worked in the military, and he suffered from several injuries due to his labor in a precarious occupation. He lacked medical coverage and was denied disability by his company. On the other hand, Bhim quickly found a stable job upon resettlement into the united states and was offered fringe benefits. These findings also demonstrate that the caste system is maintained regardless of place or time.

During their time in camps, Tika and Prakesh still followed many of the social norms associated with their social position. Although their marriage would have been forbidden under the caste system. Upon resettlement to Akron, Bhim still enjoyed many of the privileges associated with his caste, which is reflected through his abilities to navigate his

83 society. Sarah's family still encountered numerous barriers to care, which are influenced by their caste status.

These narratives also indicate that Nepali/Bhutanese youth experience acculturation stressors differently than their parents and might be less likely to follow the caste system. When Sarah was resettled in New Jersey, she reflects on how lonely she felt as a child because she could not speak to anyone. However, Sarah and Bhim's son were able to quickly master English, which helped them better navigate their host societies.

Their language allowed them to rebuild relationships with their peers and other people in their communities. Although Sarah was a member of the lowest caste, she could use the skills she cultivated in school to earn a scholarship to a local college and aspired to a career in education. Sarah also encountered additional stress because she needed to interpret English for her parents. As a member of the highest caste, Bhim had the resources to relocate his son to a more affluent neighborhood, which would offer his son more opportunities for higher education. These findings suggest that Bhutanese/Nepali youth may be less likely to follow the caste system than their parents.

There are also several limitations to this project. First, many of our respondents only spoke Nepali, and interviews needed to be interpreted into English. Some of the interpretations may not completely reflect the participants' views. Our interpreter was also well known in the Bhutanese/Nepali community, and he actively worked as a

Christian pastor. Respondents may have answered interview questions in a socially desirable way due to Santa’s presence. This project cannot directly measure the influence of caste on health, but it can offer rich insight into the lives of community members. I argue that this approach contributes to the literature on the caste system as a fundamental

84 cause because this project illustrates that the caste system persists upon resettlement into western society. Another limitation of this project is the original data did not focus on the caste system. Interviews were conducted as part of a larger project focused on substance abuse in the Bhutanese/Nepali community. However, we still collected information on participant demographics, including caste, which allows this data set to be applied to research questions related to caste, social inequalities, and health. Indeed, this dataset's benefits include an extensive sample, which reflects the diversity of the Bhutanese/Nepali community regarding gender, age, religious beliefs, and caste. Interviews were also very detailed, and the narratives presented in this chapter are reflective of the dataset’s depth.

Conclusion

This study illuminates how caste functions as a fundamental cause of illness upon resettlement and caste differences in the experiences of acculturation stressors. There is evidence that the lower castes may experience more acculturation stressors than members of the upper castes. For example, the lower castes may cling to the caste system's social norms as a coping mechanism. Next, these results indicate that higher castes have access to more resources than people in lower castes. People belonging to the higher castes might be more likely to eschew these social norms associated with the caste system and have an easier time gaining access to medical care. Finally, findings indicate that

Bhutanese/Nepali youth are less likely to follow the caste system's social norms than their parents. Adolescents and children learn English much faster than their parents, and increased access to education may offer more avenues for future employment.

Findings from our provider interviews indicate that the entire community has experienced traumatic life events associated with their flight from Bhutan. However,

85 many of these traumatic experiences are exacerbated by new acculturation stressors upon resettlement. Indeed, many community members encounter barriers to gaining employment, learning English, and accessing healthcare. Our providers stated that drinking fosters accidents, domestic violence, and drunk driving. Further, many providers were concerned that youth are abusing drugs including tobacco, marijuana, and glue.

Ultimately, these findings indicate that mental health is a concern in the community, but health disparities are further shaped by caste status.

In sum, this project contributes to the literature on social inequalities by understanding the caste system's persistence in western societies. This study finds support for the acculturation stress literature through narratives finding that members of lower castes may cling to rituals and beliefs associated with their caste. On the other hand, people belonging to higher castes may not adhere as firmly to the social norms related to their caste. This chapter also contributes to the literature on fundamental causes and cultural health capital. Participants belonging to higher castes drew from a larger pool of resources to find access to care that members of lower castes may have been unable to access. Individuals belonging to the upper castes are also higher in cultural health capital, which improves their ability to navigate their host society's healthcare systems. These findings also suggest that members of lower castes occupy positions that foster illness or injuries. For example, Sarah’s father was a member of the lowest caste and suffered from several injuries during his time in the military. In general, this project illustrates that the caste system continues to operate as a fundamental cause of health and illness upon resettlement.

CHAPTER IV

THE CASTE SYSTEM: BARRIERS TO INTEGRATION AND CARE

Since 1965, the United States has entered a new era of immigration with more racial minorities migrating from Latin American and Asian countries (Alba and Nee

1997; Kivisto 2017; Massey 1995; Rodriguez 2008). In the past, racial minorities were denied the ability to participate fully in the dominant Anglo-American culture. White immigration into the United States has been encouraged throughout American history.

Europeans were considered the most likely to conform to mainstream society and were less likely to maintain ties to their country of origin (Gordon 1964; Massey 1995). The recent influx in nonwhite immigrants is due to eliminating discriminatory policies preventing minorities from immigrating and the resettlement of refugees for humanitarian reasons (Massey 1995). Before resettlement, members of forcibly displaced populations encountered stressful life events, including rape, torture, and physical violence (Shannon et al. 2015). Bhutanese/Nepali refugees also experienced further trauma by being forced to live in camps for decades and further marginalized by oppressive policies enacted by the Bhutanese and Nepali governments (Dutton 2011).

Upon resettlement into the United States, resettled refugees encounter barriers to mental health treatment in the Bhutanese community. For example, several reports indicate that social service agencies are often underfunded and lack the resources to overcome hurdles associated with learning English, acquiring citizenship, or

87 disseminating public health information (Adhikari et al. 2015; Dutton 2011; Ott 2013;

Shrestha 2011). Resettlement agencies have received federal funding, but these resources have been reduced due to cuts made by government administrations (Ott 2011; UNCR

2018). Refugees struggling to learn English report difficulties communicating their symptoms to doctors and calling for services during an emergency (Dutton 2011; Gurung

2019; Subedi et al. 2015). Remnants of the caste system likely exacerbate barriers to mental health treatment. Further, members of lower castes are less likely than people belonging to higher castes to seek treatment for a mental health condition (Bennett et al.

2008; Dutton 2011). Lower castes often do not have the same access to resources and capital as members belonging to the upper castes, and members of the lower castes likely encounter more barriers integrating with their host societies (Gellner 2007; Subedi 2011).

Refugees unable to integrate with their host societies further encounter barriers to medical care. Bhutanese/Nepali community members who cannot find meaningful employment experience further stressors, barriers to integration, and may not seek medical treatment (Ager and Strang 2008; Dutton 2011). Members of the

Bhutanese/Nepali community living in Akron often find employment in manufacturing occupations, which increasingly do not provide adequate pay or health benefits (Gurung

2019). Refugees who do not form meaningful social connections to others report difficulties navigating their host society or feelings of isolation (Benson et al. 2012;

Dutton 2011). However, there is evidence that refugees living in Akron are establishing an ethnic enclave (Gurung 2019), which provides community members with the means of becoming economically stable and bolsters their social networks (Alba, Logan, and Stults

2000; Rumbaut 2015).

The current study examines whether the caste system presents a barrier to Akron's mental health services or if refugees encounter difficulty accessing regardless of their former social status. Prior research suggests that the lower castes are often illiterate due to discriminatory government policies, which impairs their ability to access medical care and understand public health information (Bennett et al. 2008; Subedi 2016b). Other studies suggest that higher caste refugees encounter a range of stressors associated with resettlement that may strip them of their former privileges (Patel 2012). Resettled refugees likely experience barriers to mental health treatment because they face a new set of stressors associated with the resettlement process (Dutton 2011; Lundström and den

Uyl 2010). Using 100 in-depth interviews collected in the greater Akron area, this study aims to understand variation in access to health services within the Bhutanese community.

LITERATURE REVIEW

Assimilation, Integration, and Enclaves

Numerous studies have found that racial minorities encounter difficulties assimilating to the United States and are denied the ability to participate in mainstream culture (Waters and Eschbach 1995). White immigration into the United States has been encouraged throughout American history (Gordon 1964; Massey 1995). Furthermore, restrictions on European migration were only imposed during the world wars and the cold war (Massey 1995). The assimilation of European immigrants is focused on dismantling their original culture in favor of Anglo-American values (Waters and Eschbach 1995).

White immigrants are expected to conform to the English language and the American social institutions (Gordon 1964). On the other hand, racial minorities who immigrate to

89 the United States increasingly experience racism and still report encounters with discrimination (Rumbaut 2015). Based on these criticisms, many scholars assert that assimilation theory needs to be modified to better account for the experiences of racial minorities (Alba and Nee 1997; Massey 1995; Waters and Eschbach 1995).

There are several weaknesses associated with the use of assimilation theory. For instance, the straight-line model has typically been used to account for white immigrants' experiences and has not been used to understand the experiences of racial minorities

(Alba and Nee 1997; Lee and Bean 2004; Rumbaut 2015; Waters and Eschbach 1995).

According to Esser (2010), assimilation theories are not explanatory and are based on empirical generalizations. Prior research indicates that historical events function as the causal mechanism underlying migration changes (Esser 2010; Kivisto 2017). Other scholars suggest that assimilation theory should be reframed as multiculturalism, which proposes minorities can be incorporated into society without losing their cultural traditions (Alexander 2001; Bloemraad, Korteweg, and Yurdakul 2008; Kivisto 2017).

Despite these weaknesses, contemporary scholars have increasingly reframed assimilation theories into integration, which can be applied to understand the barriers refugees encounter upon resettlement. According to Ager and Strang (2008), refugees struggle to integrate with their host societies if they cannot find meaningful employment, create social networks, and master language as well as culture. Refugees who integrate with their host societies will learn to follow social norms associated with their new society (Ager and Strang 2008; Strang and Ager 2010). Immigrant enclaves also assist refugees with the integration process, which helps refugees preserve their cultural values.

According to Gurung (2019), the developing enclave in North Akron provides members

90 of the Bhutanese/Nepali community opportunities to interact with their host society and other immigrants. Alba and Nee (1997) argue that enclaves can capture improvements in recent migrants' economic trajectories, which indicates they are more likely to integrate with their host society. Enclaves provide refugees with the means of establishing ethnic economies to become economically stable and the ability to rebuild social networks (Alba et al. 2000; Portes and Manning 2005; Rumbaut 2015).

Theoretical Framework

This project builds Ager and Strang’s (2008) framework of integration to illuminate how resettled refugees experience barriers to healthcare and integration with their host society13. I argue that Bhutanese/Nepali community members who are more integrated with their host society are better equipped than less integrated individuals to access medical care. Further, I identify several barriers to integration experienced by

Bhutanese/Nepali refugees related to employment and education, language, and culture, and rebuilding social networks. As noted in earlier chapters, barriers to integration also function as sources of acculturation stress14 experienced by Bhutanese/Nepali refugees upon resettlement into their host society (Alba and Nee 1997; Strang and Ager 2010). For example, the inability to reestablish social networks exacerbates stressors upon

13 As discussed in the literature review, I have used integration theory rather than assimilation theory. According to Ager and Strang (2008) migrants acculturate to their host society on different dimensions but can retain some values and beliefs from their society of origin. These dimensions are useful for understanding social inequalities related to the caste system. Further assimilation theory is viewed as failing to address the beliefs of non-European migrants and refugees (Esser 2010; Rumbaut 2015; Waters and Eschbach 1995). Therefore, I refer to the processes associated with acculturation as integration.

14 As noted in other chapters many of the barriers to integration and treatment experienced by Bhutanese/Nepali refugees also function as acculturation stressors. In this chapter, stressors are also referred to as barriers because they reduce the ability of Bhutanese/ Nepali community members to find care, cope with stress, and integrate with their host society.

91 resettlement (Lundström and den Uyl 2010) and deprives resettled refugees of coping mechanisms (Dutton 2011).

Based on figure two, individuals with access to more economic resources encounter fewer barriers to integration with their host society and healthcare (Strang and

Ager 2010). Individuals with more extensive social networks are also more likely to be integrated with their host society (Alba et al. 2000; Portes and Manning 2005; Rumbaut

2015), which increases their ability to use medical care (Ager and Strang 2008; Strang and Ager 2010). Finally, integration theory posits that individuals who master their host society's language will encounter fewer barriers to integration and medical care (Dutton

2011; Strang and Ager 2010). Prior research indicates that higher castes have access to more economic and social resources (Subedi 2016), suggesting that they may encounter fewer barriers to integration with their host society. Ultimately, this project will illuminate how social inequalities continue to shape healthcare access upon resettlement in the United States and Northeast Ohio.

Employment & Integration with Access to Care Education Host Society

Social Networks Language & Culture

Caste Status

Figure 2: Theoretical Model of Barriers to Care and Integration

Economics and Barriers to Integration and Healthcare

Bhutanese refugees are frequently resettled into impoverished neighborhoods, which further intensifies traumatic life events and stressors (Kohrt et al. 2012). Many of these areas are beset by criminal activities and have limited employment opportunities

(Kohrt et al. 2012). Refugees living in violent communities also struggle to integrate into their host communities and reestablish social networks (Ager and Strang 2008). Refugees resettled into economically disadvantaged neighborhoods feel they need to avoid interacting with other people to avoid trouble (Ager and Strang 2008). Scholarship conducted by Dutton (2011) further indicates that Bhutanese refugees are more likely to encounter discrimination from host communities because they are viewed as straining scarce economic resources. In Akron, African American community leaders feel that the city has not provided them with the same financial resources as immigrants (Gurung

2019; Hindi 2019).

Resettled refugees further report that their education and professional training often is not recognized in the United States (Ager and Strang 2008). Bhutanese refugees living in Akron increasingly take low-paying manufacturing jobs at factories and warehouses (Gurung 2019). There is substantial evidence that resettled refugees do not find work in the manufacturing sector fulfilling and want to find an occupation with higher compensation, opportunities to utilize skills, and autonomy (Dutton 2011; Gurung

2019). Bhutanese/Nepali refugees also assert that they have lost the most productive years of their lives during their time in the camps because they could not work, learn a new trade, or provide for their families (Dutton 2011; Shannon et al. 2015). Research conducted by Pearlin et al. (1981) finds that people experiencing stress-related

93 disruptions to employment are more likely to develop depressive symptoms. Having lower social-economic status also increases the risk for developing mental health conditions (Hatzenbuehler et al. 2013; Link and Phelan 1995; Thoits 1995).

Gurung (2019) has found that refugees living in the Akron area report difficulties finding work, especially during the great recession, and refugees increasingly operate small businesses to become financially stable. Bhutanese/Nepali refugees also work in small businesses because their work fosters feelings of control and autonomy (Gurung

2019). According to Pearlin (1981), individuals who report feelings of control and self- esteem are less likely to develop depressive symptoms. However, Bhutanese/Nepali business owners report struggling to manage their organizations based on a lack of business acumen, high rent, building code violations, and break-ins (Gurung 2019).

Problems owning a business are likely exacerbated by membership in a lower caste or inability to integrate with their host society. For example, refugees belonging to higher castes have access to more resources (Gellner 2007), which may ameliorate the difficulties associated with managing a business. There is also evidence that non-

Bhutanese small business owners already living in North Hill view businesses owned by resettled refugees as threats. Indeed, members of the Bhutanese/Nepali community report encounters with discrimination from other business owners and feel they are taken advantage of by local investors (Gurung 2019).

Interviews conducted by Gurung (2019) indicate that resettled refugees living in the Akron area are developing enclaves, which bolsters the financial well-being of community members. Enclaves are defined as resilient communities, which preserve their traditions through the mutual support of migrants of the same ethnicity (Alba et al. 2000;

Portes and Manning 2005; Rumbaut 2015). Additionally, immigrants often geographically ground themselves in one area, which helps them maintain ties to their cultures and are composed of a variety of small businesses owned by individuals of the same ethnicity (Alba et al. 2000; Portes and Manning 2005; Rumbaut 2015). According to Gurung (2019), dozens of businesses are owned by Bhutanese of Nepali descent in

North Akron, including several grocery stores, garment shops, jewelers, restaurants, and community health providers. Refugees and migrants living in enclaves can also establish social ties with others and preserve their cultural identities (Portes and Manning 2005;

Rumbaut 2015; Waters and Eschbach 1995).

Ott (2013) asserts that American social services are increasingly understaffed and lack financial support to assist incoming refugees adequately. Resettlement agencies increasingly report being underfunded and are often forced to slash caseworker positions.

Certainly, caseworkers are the backbone of resettlement agencies responsible for providing new arrivals with orientations, integration, and employment services (Hoellerer

2013). While we were collecting our data, The International Institute of Akron needed to lay off caseworkers and had lost more than one-third of their budget. New programs are also becoming increasingly difficult to develop without adequate government support

(Hoellerer 2013). Local social service agencies struggle to teach a sufficient number of

English classes and direct refugees to potential employers (Dutton 2011; Ott 2011).

Bhutanese refugees also complete secondary migrations to several cities in the

Northeastern United States including Pittsburg, Columbus, and Akron (Adhikari et al.

2015; Ott 2011). However, most agencies do not have the resources to support the influx of new migrants, and most services are only provided at the original place of resettlement

(Adhikari et al. 2015; Ott 2011). Inadequate social services also prevent refugees from gaining access to the classes they need to acquire American citizenship (Dutton 2011; Ott

2013). Refugees who are denied citizenship report having experiences with trauma, feelings of not belonging, and statelessness (Dutton 2011).

Social Networks as a Barrier to Integration and Healthcare

During the resettlement process, families were often separated from each other when relocated to different nations or states. Being split from family members is frequently reported as a stressor for Bhutanese/Nepali refugees (Lundström and den Uyl

2010). Family is significant to members of the Bhutanese community, and interconnectedness with others is an essential element of their culture (Benson et al.

2012; Dutton 2011; Lundström and den Uyl 2010). Younger members of the Bhutanese community value caring for aging parents and are often expected to serve as primary caregivers (Lundström and den Uyl 2010). Conversely, the family may become a life strain when refugee parents are not treated for their encounters with traumatic life events, or ongoing life strains are passed on to children (Dutton 2011).

Bhutanese/Nepali refugees are increasingly unable to maintain their social networks during the resettlement process because family and friends are resettled into different locations (Dutton 2011; Lundström and den Uyl 2010; Ott 2011). In-depth interviews conducted by Lundström and den Uyl (2010) have found that refugees separated from family members report feelings of isolation, sadness and feel they are becoming finically unstable. Refugees who report feelings of social and familial support experience a buffer against developing depressive symptoms (Downing and Garcia-

Downing 2009; Pearlin et al. 1981; Thoits 2011). When possible, refugees often complete

96 secondary migrations closer to family members living in other states (Ott 2011).

However, secondary migrations seldom occur when family members are resettled to different countries (Lundström and den Uyl 2010; Ott 2011).

There is also evidence that remnants of the caste system may also prevent lower castes from developing a social network with other members of the Bhutanese community. People belonging to higher castes are sometimes reluctant to interact with a lower caste (Dutton 2011; Patel 2012). Members of lower castes also report overt discrimination from individuals belonging to higher castes (Patel 2012). When resettlement services expire, caste-based discrimination may also harm new refugees' ability to navigate their communities. Newly resettled refugees increasingly rely on previously resettled community members to help them access social services (Hoellerer

2013) and integrate with their host societies. Ott (2013) has found that members of the higher castes were resettled before people belonging to lower castes. Therefore, the resettlement process may create conditions where disadvantaged community members may need to rely on the upper castes.

Language and Culture as a Barrier to Integration and Healthcare

Ager and Strang (2008) have found that refugees struggle to integrate into their host societies who have a low level of English mastery. Language barriers restrict the ability to find meaningful employment, become financially stable, and navigate host societies (Ager and Strang 2008; Hodge 2004). Resettled refugees also struggle to access mental health services due to difficulties in learning English (Dutton 2011; Subedi et al.

2015). Dutton (2011) asserts that the language barrier often prevents newly resettled refugees from navigating medical coverage, practicing preventative care, and

97 understanding patient rights. Often Bhutanese/Nepali refugees only seek medical care during emergencies and report feeling uncomfortable interacting with medical professionals (Dutton 2011; Subedi et al. 2015). According to Bennett et al. (2008), members of the lowest caste (Shudra) are least likely to engage in health-seeking behaviors, and lower castes are less likely than members of higher castes to seek treatment.

Refugees who are unable to speak English also report feelings of isolation and a disconnect from other people. Older adults who cannot leave their homes report feeling lonely because they cannot interact with others (Hinton 2016). The stress process model indicates that isolation functions as chronic stress, fostering depressive symptoms

(Pearlin et al. 1981; Thoits 2011). In-depth interviews conducted by Miller and Rasco

(2004) have found that refugees report rarely having anyone to talk to --even if they are active in their communities. Refugee feelings of isolation are intensified if they are resettled in neighborhoods without other community members (Ager and Strang 2008;

Miller and Rasco 2004).

Immigrants' descendants integrate with western societies faster than their parents, which produces a generational gap between parents and children (Alba 2005; Rumbaut

2015). Subsequent generations are less likely to follow their parents' cultures, and their original ethnic identity withers over time (Alba and Nee 1997; Rumbaut 2015). Through their compulsory education, children have learned the social norms they need to follow in an emergency, like calling 911 and speak English to the operator. According to Gurung

(2019), Bhutanese/Nepali refugees in Akron do not contact the police because of the barriers they encounter speaking English. Inability to speak English further exposes

98 families to stress because parents become dependent on their children for help navigating the community (Dutton 2011). For example, children are increasingly needed to translate for their parents while interacting with medical professionals and often make medical appointments (Dutton 2011).

In this chapter, I examine whether resettled participants of higher castes will encounter fewer barriers to accessing social service providers than members of lower castes. Several studies have found that Bhutanese/Nepali refugees experience barriers to treatment upon resettlement into their host society (Dutton 2011; Lundström and den Uyl

2010; Subedi et al. 2015). However, few studies have looked at how caste shapes

Bhutanese/Nepali refugees' experiences upon resettlement. I anticipate that the upper castes would encounter fewer barriers to treatment than individuals belonging to the lower castes. On one hand, people belonging to the higher castes are often more educated, have vast social networks, and more economic capital (Gellner 2007; Subedi

2011).

On the other hand, people belonging to lower castes are often less educated, experience discrimination from within their communities, and are more likely to work in low-status occupations (Gellner 2007; Patel 2012; Subedi 2011). I propose two research questions to understand the barriers to treatment encountered by resettled refugees. First, how does caste status prevent refugees from accessing social services and mental health treatment? Second, what are the other barriers resettled refugees encounter when attempting to access social services and treatment?

METHODS

Data for this project consists of in-depth interviews conducted with 100 resettled members of the Bhutanese community15. These interviews were collected as part of a larger project called the Bhutanese Refugee Substance Abuse Study (BRSAP), which includes some data not used to address these research questions. Our research team employed an interview guide with community members centered on four areas: perceptions of the Akron Area, access to social service, perceptions of substance abuse, and potential community-based mental health solutions.

Additionally, there were 20 interviews conducted with professionals/providers who provided community members with a range of social services. Agencies sampled include behavioral health centers, resettlement agencies, community health centers, social service agencies, and law enforcement. Each of these interviews was transcribed using

Express Scribe software, and the data was analyzed and coded thematically using NVivo

12 Pro.

Sampling Strategy and Coding Procedures

We employed snowball sampling to contact the first 80 community members.

Prior research suggests that the use of snowball sampling provides researchers with easier access to vulnerable populations (Sadler et al. 2010). Resettled refugees were exposed to

15 The interviews for this project were collected by Dr. Marnie Watson, a Research Associate at the University of Akron and Assistant Professor of Anthropology at Missouri State. Research assistants from The University of Akron. Research assistants on the project had some background in the social sciences and were enrolled in graduate or undergraduate degrees including sociology, anthropology, and psychology. Research assistants working on the project are Jimmy Carter, Nuha Alshabani, Julian Curet, Vyshu Ramini, and myself. We divided the labor amongst the research team members who completed interviews with community members, transcribed interviews, created a codebook, and analyzed the data. I conducted interviews with thirty-three community members and three providers. Field sites were located at participant households and social service providers in the community. Our team worked with Santa Gajmere, hired to be our translator. Santa was responsible for obtaining oral consent from community members, translating interview questions, and debriefing participants.

100 traumatic life events and may have been reluctant to talk to our research. Theoretical sampling was informed by prior data collection and employed to ensure that each of the castes living in the Akron area is adequately represented in the final sample. Our team targeted respondents based on their gender, caste, age, and religion, which ensured that each of the community's major groups was represented in our sample.

Our research team began our coding procedure with open coding and coding the interviews line by line. According to Corbin and Strauss (1990), this allows researchers to start identifying themes and make sense of large amounts of data. Indeed, using open coding provides researchers with a foundation for theory building (Charmaz 2008;

Corbin and Strauss 1990; Glaser and Strauss 1967). Finally, interviews were analyzed using focused coding, and the most frequent themes from the interviews were carefully inspected. Focused coding further allows researchers to select the themes that make the best sense of an empirical phenomenon (Charmaz 2008; Corbin and Strauss 1990). Our research team coded the first five interviews to develop a codebook before proceeding with coding to ensure reliability. Any discrepancies in coding were discussed during weekly team meetings16.

16 The Institutional Review Board approved this project at the University of Akron. Written informed consent was obtained from each of our participants, and an interpreter was present to ensure they understood the consent forms. Before the interviews took place, interviewees were informed about the purposes of the interviews and the risks associated with participating in the study. To protect participant confidentiality, recordings of interviews were stored on a password-protected cloud-based server. Participants could contact a member of the research team if they wanted to have any of their information destroyed.

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Community Member Characteristics

Men composed over half of the sample (55 percent), and women were 45 percent.

On average, participants were 40 years old. The youngest respondent was 19 years old, and the oldest respondent was 70. Most of our sample practiced Hinduism (34 percent),

Christians consisted of 30 percent, Kirat was 23 percent, and the remaining 14 percent were Buddhists. Regarding the caste system17, Brahmin comprised 23 percent of the sample, Chhatriya was 24 percent, Vaisya composed 30 percent, and Shudra made up 24 percent.

Table 9: Summary Statistics Demographic Mean/Percent Gender Male 55% Female 45% Age 40 Religion Christian 30% Hindu 34% Kirat 23% Buddhist 13% Caste Brahmin 23% Chhatriya 24% Vaisya 30% Shudra 23% Total 100%

Provider characteristics

Women composed 60 percent of the provider sample, and the remaining 40 were men. Two of the respondents worked for behavioral health centers, which focused primarily on treating mental health and substance abuse conditions. Four interviewees

17 Bhutanese society conforms to the caste system. The lowest caste is the Shudra, which consists of laborers and servants (Gellner 2007). Next, the Vaisya caste consists of merchants, artisans, and craftsmen. Chhatriya are a higher caste, which consists of administrators and rulers (Gellner 2007). Finally, the Brahmin are the highest caste and consist of scholars and priests (Gellner 2007; Subedi 2016b).

102 worked at resettlement agencies responsible for helping community members access housing, employment, and medical treatment. Six respondents worked at a community health center, which focused on providing culturally competent care. Seven were employed at agencies offering a broad range of social services related to resettlement, employment, and health. These agencies offered their services to everyone and not just the Bhutanese/Nepali refugee community. Finally, one participant worked in law enforcement who interacted with Bhutanese/Nepali community members.

Table 10: Provider Characteristics Demographic Frequency Percent Organization Type Behavioral Health Services 2 10% Community Health Center 6 30% Law Enforcement 1 5% Resettlement Agency 4 20% Social Services 7 35% Gender Male 8 40% Female 12 60%

COMMUNITY MEMBER RESULTS

Accounts from community members reveal that resettled Bhutanese/Nepali community members encounter several barriers to seeking mental health treatment and integration with their host societies. I identify four barriers, which often intersect with the caste system including stigma, social networks, employment, language, and culture.

Findings are presented and organized using the crosstab feature in Nvivo12.

Stigma as Barrier to Integration and Healthcare

Findings from the crosstab analysis indicate that more than half of participants (67 percent) reported that stigma was the most significant barrier they encountered when

103 seeking treatment. There were 38 members (57 percent) of lower castes and 28 members

(43 percent) of upper castes who believed stigma was a barrier to integration and health services.

Regardless of caste, most respondents asserted that people who engage in problem drinking or have a mental health condition are bad people. One Brahmin woman (age 29) asserted: "Never believe and never trust that person…[They] do not... change the heart… or change the mind. They will never get corrected". When asked what people in the community think about someone who drinks, she asserted:

So, in our community, anybody who drinks is taken as a bad personality in our society. They will think it; They will say, “Oh, the drunkard is coming. Or the bad person is coming. A person who never changes is coming.” That’s how they address those people or say about the people.

Her response underscores that people who drink are viewed negatively by other

Nepali/Bhutanese community members. Members of higher castes are not permitted to drink, and some scholars suggest that drinking is more stigmatized for members of the

Brahmin and Chattriya castes (Dhital et al. 2001).

Members of the lower castes echoed the sentiments of people belonging to higher castes and asserted that people who engage in problem drinking are feared by others in the community. When asked about the stigma associated with problem drinking, a Vaisya man (age 45) asserted:

Those who drink… They misbehave… They do not act good. They do not deserve

respect. And if anybody respects them in spite, they turn out bad… Nobody can

control… He does not listen to anybody else.

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Members of the lower castes may consume alcohol as a part of their religious ceremonies or cultural traditions (Dhital et al. 2001). Lower caste drinking behaviors illustrate that alcohol use might be less stigmatized for members of the lower castes. However, this community member stresses that Bhutanese/Nepali individuals who engage in excessive alcohol consumption are seen as bad people.

When asked about mental health, one married couple from the Vaisya and

Chattriya (lower and upper) castes asserted that members of the Bhutanese/Nepali community never want to seek treatment for mental health conditions because "They fear being defamed".

They feel bad about that [mental health]. Because mental health is not openly discussed back home. Because people are not talking about mental health. And they’re not seeking help if there is some kind of problem… They stay home, you know. So, we need help with that too here. Even they get depressed, you know, like some depressions, they don’t wanna, you know, seek help from the doctor here. They think like, “Oh, what’s going on?”. Just let it be… and it will be worse.

These respondents underscore that mental health problems are not discussed by people living in the Bhutanese community. Indeed, several studies have found that

Nepali/Bhutanese fear people with mental illnesses as physically violent (Shannon et al.

2015).

Social Networks and Social Isolation as Barrier to Integration and Healthcare

There were 40 of 100 community members (40 percent) who reported barriers to integration and access to healthcare associated with maintaining their social networks.

There were 21 members of lower castes (53 percent) who encountered obstacles to integration and care. The other 19 participants (57 percent) who experienced barriers to reestablishing social networks belonged to the upper castes.

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Isolation. Half of these respondents (20 of 40) reported that community members felt isolated from others because they could not speak English or struggled to integrate with western culture. Nine members (45 percent) of the lower castes (Shudra and Vaisya) reported community member isolation. Only two members (ten percent) of the Chattriya caste described barriers associated with isolation. There were nine members (45 percent) of the highest caste (Brahmin) who reported isolation presents resettled refugees with a barrier.

Most participants reported that immigration to the United States fueled social isolation due to cultural differences in social interaction. One Vaisya man (56 years old) explained:

American people stay in their houses. So that's why nobody knows whether

there's a person inside the house or not; nobody knows. But Nepali friend… I

think you might have seen before they come out they go here and there… But

American friends. I haven't seen anybody coming out. And nobody knows who's

there…

His response underscores that people living in America are independent, which differs dramatically from the collective environment in their society of origin. Bhutanese/Nepali community members remained connected during their time living in refugee camps but often struggled to establish these connections upon resettlement (Dutton 2011).

A majority of people belonging to the upper castes stressed that older community members were the most at risk for struggling to rebuild their social networks. When asked about older adults feeling isolated, a 25-year-old Brahmin woman explained:

The main reason is that the same thing they are illiterate they don’t how to speak the American language and then they cannot even drive they can’t take the driver

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license because they don’t have language so and then your family members may be the son or daughter need to go to work and they don’t have the time. This makes people have nothing to do, and they feel lonely.

Her response is consistent with several studies finding that older adults are at an increased risk for developing feelings of isolation due to gaps in language and acculturating to their host society (Dutton 2011; Hodge 2004).

Feeling unsafe. Half of the respondents (20 of 40) reported that they did not feel safe in their neighborhoods, which hinders the integration of resettled refugees with their host society. There were 11 (55 percent) individuals belonging to the lower castes, and the other nine respondents (45 percent) were part of the upper castes.

One Vaisya man (age 45) reported that his aunt was robbed coming home from a local jewelry store. He asserted that her assailants took everything of value and family members were unable to help her after the assault.

Four days ago. So, one of our relatives we're returning from the gold store. After

buying… They might have bought some jewelry, and they were coming on the

way as far as he knows, few Americans… They look like African Americans, and

they kidnapped… They would have like a Social Security card and some other

family documents, whatever they had in first that they took it out, along with that

one. The handle of the not… what's it… the gun… gun… the handle… they hit.

Not with the bullet… but with the handle of the gun… She got wounded…. It

was the daytime… Her sister called regarding that incident, and she was crying

and calling for help. So, all his relatives went to find out what was wrong, but the

attackers were not there. They ran away!

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This respondent indicates that his family members were directly affected by violence at a local jewelry store in North Akron. Kohrt et al. (2012) remind us that Bhutanese/Nepali community members were often initially resettled into neighborhoods affected by violence.

One couple described when two African American men broke into their home.

The husband (Shudra, age 45) indicated he tried to call their children for help but felt afraid to directly confront the intruders:

They had a knife… I called my children saying, Come on! Come down! I didn't

know what type of person entered our house. So, I felt like they were like two

words… like… my sound could them make [the intruders] weaker. So, I do not

think it's wise to do anything to them because both of them with the knife on the

other side, so I just stared at them.

The respondent continued that the intruders took their personal documents including an identification card, banking information, insurance card, and money.

Members of the upper castes reported encounters with crime before coming to the

Akron area. Respondents belonging to the higher castes described that they came to

Akron because they believed it would be safer than their initial point of resettlement. One

Brahmin man (39 years old) reported that he left Oakland due to his perceptions of criminal activities and wanted to be closer to family members resettled in Akron.

So, what happened was over there. There was a lot of crime, especially in Oakland. But and there are my relatives over here, so I moved here. We are more than eighty families [who] moved from that Oakland to other parts of the states, not only Akron. Most of them move to Ohio, but some in Pennsylvania. So, the main cause of there is like uh, you know, the security reason, and high expenses.

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This respondent further indicated that he had the resources to relocate to be closer to his family members. Indeed, several scholars suggest that Bhutanese/Nepali complete secondary migrations and members of the upper castes may have the resources to complete secondary migrations (Lundström and den Uyl 2010; Ott 2013). However, community members of lower castes may not have had access to the same resources to resettle and may be forced to endure in neighborhoods beset by violence.

Divided families. Only 13 community members stated that divided families impaired their abilities to rebuild their social networks. A majority of respondents (11) belonged to the lower castes (79 percent), and the other two respondents (14 percent) were from the upper castes.

One Shudra man (age 57) asserted that life in the refugee camps allowed him to maintain his connections to the other people in his family. Upon resettlement, he reported losing the connections he had to his family and being unable to maintain the connections he had in the camps:

We were together, our community people were together in the refugee camp […] Everybody, all of us working together, going house to house, like meeting relatives, right. If there was any, any kind of religious program, we go there […] When we came here, we were taken to a different state of the country. And my brothers, my old house, my brother, my sister, you know, the one family, we were there in the camp in one, one hut, you know. Ten people, eleven people, twelve people. When we were taken here, we were separated for good.

This respondent illustrates the expectation that extended families are considered one unit in the Bhutanese/Nepali community. However, resettlement policies in many western societies are often insensitive to the needs of the community. Most nations resettle community members as nuclear families, and extended families are often resettled into other countries (Lundström and den Uyl 2010; UNCR 2018).

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One man from the Vaisya caste (33 years old) asserted that he lost the connection he had to his aging parents and moved to Akron to care for them. When asked about his experience with the resettlement process, he stated:

Uh… The reason is that my parents are quite old and uh they are physically and mentally sick, and I have only one brother, so he has too good a job, but it is difficult for him to manage time to look after my parents.

This respondent indicates that the expectations of caring for his parents provide additional stress after resettlement. Several studies further demonstrate that children are expected to take care of their parents, and family is an influential social network (Dutton

2011; Hodge 2004; Lundström and den Uyl 2010).

The only member of the upper castes, a Brahmin man (age 55), asserted that some people might engage in problem drinking if they are separated from their extended families. He claimed that an inability to meet social expectations fueled problem drinking:

Yeah, there can be other issues like maybe the son is here and the mother and sister to come with somebody else and with a brother in Nepal father in Bhutan. So, we know that like all these unfulfilled desires come in them and with that they when they find no solution, they go for alcohol.

This community member stresses that separated families constitute a significant source of acculturation stress for Bhutanese/Nepali refugees. However, members of the upper castes were more likely to be resettled before people in lower castes. The higher castes may have had the resources to complete a secondary migration closer to members of their extended families (Ott 2013).

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Employment as Barrier to Integration and Healthcare

There were 37 of 100 community members who asserted that there are barriers to finding employment. A greater number of lower caste community members (68 percent) reported experiencing barriers to employment than members of the upper castes (32 percent).

Lack of available jobs. There were 14 of 37 community members who reported that finding work was a barrier to integration. There were 11 members of the lower castes

(79 percent), and the remaining 3 (21 percent) belonged to the upper castes.

On the one hand, both members of the upper and lower castes also reported difficulties finding work in the Akron area. One man (age 32) from the lowest caste

(Shudra) indicated that he believed there were more jobs in neighboring communities for the Bhutanese/Nepali community members. However, the respondent indicated that there were no local jobs available:

I found many of our people working in other cities than Akron. So, there is no job

like… like; you know… entry-level jobs. I don't find any… So, I'm looking for a

job, but it's not that there is no job. I hope my god has a better plan. But… But

everyone doesn't look like that… So, I have heard about they have been building

some warehouse in Talmage.

Another respondent (age 29) from the highest caste (Brahmin) indicated that she seldom encountered difficulties finding local work when she lived in Iowa. During our interview, she claimed that "[Iowa] was really nice, but it became like the compulsion to move [to Akron] because of my personal home situation". She reported encountering difficulty finding a job in the Akron area:

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[In Iowa] it took fifteen minutes to reach the place or workplace where I used to job, my job. And number one uh, so only fifteen minutes, fifteen minutes to job. Nextly, plenty of jobs available in Iowa. So, if you leave the one work, then there are ways to get another job. But here, you have to struggle a lot.

This respondent underscores that she had access to superior social services during her time living in Iowa and easily found a job. According to Ott (2013), members of the higher castes were more likely than others to be resettled into communities with better- funded social services programs and more opportunities

On the other hand, several Shudra and Vaisya (lower) castes stated that they could not find work and reported moving to Akron because they believed there were more entry-level positions. One Vaisya man (age 25) stated that he struggled to find work in

Maryland because of his education, and he believed that there would be more opportunities for employment in Akron:

Um, the reason why I moved to Akron is, um, because of lack of um, education. Our people didn’t get in the right job, right. So, if we have to say, if we got a job also, we need to go a little bit far from the real uh, area where we live, right. I heard that, that uh, more Nepalese folks and that more uh, openings, like a job here in Akron. So, from the case of those, my colleagues, I hear good news from them. And I start my journey from Maryland to Akron.

One Vaisya man (age 33) who moved to Akron from Virginia asserted that there were also limited job opportunities in her initial resettlement point. She explained that she moved because she believed there would be more work opportunities:

Yeah, it was pretty good living in Newport News um but um there are some things, yeah, that made us move from there like there were quite limited jobs, and job opportunities, and because of that reason people started moving to different cities, different States, and it is because of that reason that whatever we were there, we moved to different places.

Our respondent accentuates that she believed that there would be more job opportunities for her in Northeast Ohio. Some scholars suggest that the Bhutanese/Nepali community

112 in Akron is becoming an enclave due to secondary migrations from other cities in the

United States through perceived opportunities for employment and economic development (Gurung 2019). Additionally, members of the Vaisya caste may also be starting businesses by following their caste's social norm, which includes working as merchants or practicing a skilled trade (Gellner 2007; Subedi 2011). Scholars also suggest that enclaves assist migrants with social and economic integration with their host society (Alba et al. 2000; Portes and Manning 2005; Rumbaut 2015), which likely provide community members with increased access to social services.

Skills not recognized. Just seven of 37 community members (19 percent) reported that they cannot use their former skills and education in the United States. All seven were members of the lower castes and only one member of the upper castes who could not practice skills before resettlement.

When members of the lower castes do find jobs, it is often industrial work that many community members find unfulfilling (Gurung 2019). One Shudra man (age 44) lamented that he could not find work as a farmer and complained that many

Bhutanese/Nepali are forced to work in the manufacturing sector:

So, there were so many fields, like orange fields or certain types of fruits and vegetables from which we could, we used to get some money and pay back those debts. But here, no sources. So here, the company, working different kinds of industrial companies, only the source of income. That’s why people, they hate, like frustrated.

This respondent accentuates that living in Northeast Ohio has prevented him from finding meaningful work. Respondents from every caste often worked in agricultural communities and described wanting to engage in occupations related to farming (Gerber et al. 2017; Hartwig and Mason 2016; Ott 2013).

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One Shudra woman (age 19) mentions that many community members worked in skilled trades such as construction but are often able to find work in the same occupation.

She stresses that this often occurs because community members do not have a relevant degree or credentials:

A lot, lot, lot of people back in Nepal like, they used to make buildings and stuff like that too, you know that’s like, that’s um, basically they work for those to make buildings and all that. I think people, here is the problem is they need a degree for everything. But like they have experience. They know how to do all of that stuff. But they just can’t get that job because they don’t have a degree or a certificate to show it. I think it’s just so hard. Cause, um, one of my friend’s dad, he used to just like make a building. He can do it by himself, but he has so many skills… But he works in a chicken company because he has no degree to show.

Gurung (2019) reminds us that many Bhutanese/Nepali community members living in the

Akron area often worked in the manufacturing sector. Many of the resettled refugees working at local chicken factories are often paid minimum wage (Gurung 2019).

Furthermore, many of these occupations often do not provide employees with fringe benefits (Gurung 2019), which further impairs community members' ability to access care. Many of the individuals finding work in the manufacturing sector are likely members of the lower castes.

Language and Culture as Barrier to Integration and Healthcare

Almost half of the community members (49 percent) reported that English prevented them from integrating with their host societies. There were 26 respondents (53 percent) who belonged to the lower castes, and the remaining 23 respondents (47 percent) were from the lower castes.

Ability to Access Providers. Some respondents (16 of 50) reported that English prevented them from accessing medical care or social services from local providers.

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There were six respondents (38 percent) who belonged to the lower castes. Ten of the respondents belonged to the highest castes (62 percent).

A few members of the lower castes explained that inability to speak English often impacts their abilities to navigate their communities and gain accessing social services

One adult (age 32) Shudra man explained:

I am very new, at that time, I was unknown about America, unknown about the culture, everything I was new, even the people. And I was even not about to talk in English also. Cause I did not understand at that time. I was very confused. Still to this time also, I don’t understand your tongue perfectly. So, at that time, I faced many problems, like going to the office and going to the Job and Family office sometimes, and sometimes somewhere else.

This community member demonstrates that he encountered barriers to acculturation through his difficulties speaking English and understanding the norms associated with his host society. His response further illustrates that he encountered problems gaining access from local social service providers.

Members of the Chhatriya caste also explained that Bhutanese/Nepali community members would struggle to access care if they cannot speak English but emphasized that local agencies were inefficient at providing care. One middle-aged woman (54 years old) felt that community members are not provided with adequate social services and may struggle to explain their problems to providers. When asked about how the International

Institute could improve programming, she explained:

[What I feel] about International Institute that they have to improve instantly. What I feel is, before, anybody those who wanted to meet any case manager or any individuals who are working in International Institute were like, they were like available. They could go and talk to them. But now, they have to stay outside. They have to write the name. They will call, and they will come and visit. But I do not know whether this is effectively implemented. But as far as I know, those who cannot speak English, that’s a great problem because they cannot speak English and express their feeling.

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This respondent also heard other community members had difficulties making appointments with caseworkers due to increasing numbers of refugees migrating to

Akron and massive budget cuts at resettlement agencies. She continued: "As the new refugees kept on increasing, I heard about the increasing inability of accessible of getting in touch them". Indeed, many agencies have had their budgets slashed and lack the staff to tend to their clients (Ott 2013; Shrestha 2011).

Members of the Brahmin caste (highest) indicated that they were provided with

Nepali interpreters who were not trained to provide culturally competent care. One 31- year-old Brahmin man expressed his frustration that the interpreters working from local agencies failed to maintain a professional demeanor and did not provide correct translations for his mother's symptoms.

I took her to the hospital, but she started having belly pain. I tried to tell the

interpreter to see to her pain. They translated it another way. And I said, please go

away... I am laughing… And I told the doctor, “Can I interpret for my mom? I can

do it! I know my mom better than this guy. Tell him to go! Go back to the

International Institute”. And he started to be rude to me. “This my job! This my

job…! And I told the interpreter, “If this is your job, it’s fine... But please

translate in a good way.”

He continued that the Nepali interpreter "Did not use the correct words. My mom is asking about bone pain. They are talking about the stomach belly pain". Nearly all members of the highest caste reported a similar experience when dealing with healthcare providers.

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Dependence on Children. There were 22 of 49 community members who reported that they were dependent on children for accessing care. Other respondents indicated that children could use their knowledge of social services to wield power over their parents.

Approximately 59 percent (13 of 22) of them were in the lower castes, and the other 41 percent were in the higher castes (9 of 22)

People belonging to the lower castes stressed that children often use their knowledge of English to take advantage of their parents. One Vaisya man (age 36) explained:

So, if Nepali people have to call the police… The children can speak English… But they may twist the language. So that’s why after all, after all, parents who are victims. Because the police will not listen to parents, because of parents. The parents do not know how to speak English. The children are taking advantage of their families.

This respondent indicates that children often call law enforcement officers due to their parents' inability to speak English (Gurung 2019). Parents may also engage in physical forms of discipline when their children misbehave. However, schools often instruct children to call the police because they are victims of child abuse. He continued, "If the police really could understand what the parents are saying, and understand the feelings and thoughts of parents, and how to discipline their children, I think that would help."

Members of the higher castes often reported that parents might need to rely on their children for assistance navigating their communities. One 23-year-old Brahmin man explained that:

I think the main reason is uh, you know, the misconception, you know. For each sense, like uh, the parents who come here, they kind of depend on kids. And then the kids, they speak English, but the parents don’t. So, they don’t have anything to do, cause like back in their country, they can, you know. They can relate to themselves because they speak the same language. But over here, they need kids’

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help, you know. And kids uh, like, they think that since the parents are dependent on them for everything, you know. Like, the main thing is communication, which is needed, you know. So, like, kids, they don’t care. Cause like, the parents, they don’t know what the kids are doing, you know. Cause they don’t have all the communication. So, I think it is very important to have uh, communication, you know. Like that was the main reason, and the kids, they think that they are the best because they speak English, you know.

These community members indicate that adults often encounter additional stressors because they become dependent on their children when interacting with other people in their communities. Several studies suggest that Bhutanese/Nepali children are often responsible for helping their parents interact with healthcare providers and access social services (Gurung 2019).

PROFESSIONAL/PROVIDER RESULTS

Interviews conducted with providers further illuminate barriers community members encounter when seeking treatment for a condition related to mental health or substance abuse. Findings reveal that the caste system may restrict treatment if members of lower castes are providing care. Other results indicate that members of higher castes might be pushed into treatment due to the stigma attached to consuming impure subjects.

Caste and Barriers to Treatment

In our sample, 15 of 20 providers (75 percent) indicated that the caste system influenced mental health or substance abuse treatment.

One focus group conducted with a large social services agency indicates that community members do not want to be treated by caseworkers belonging to lower castes.

They provided our team with an example of senior community members who did not want to consume meals prepared by members of lower castes:

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I think the caste system limits resources for the community because of who they want to receive services. I've seen this with a senior program here. We had a senior program, Bhutanese. They're all different Bhutanese people, and then one and then they also have some meals each time they come. One time they were the meals were prepared by people in lower castes. And that affected though, like the seniors from they didn't want to eat that meal that was prepared. So, I could see that also in getting services from people, Bhutanese caseworkers even or how they give and receive services to each other.

Members of this focus group stress that the caste system directly shapes the ability of community members to gain access to medical treatment or social services. There is substantial evidence that people from the higher castes cannot consume products prepared by people from the lower castes (Gellner 2007; Subedi 2016b).

One Nepali provider working at a behavioral health center asserted that it is normative for lower castes to consume alcohol and are less likely to receive treatment for substance-related disorders. He explained that members of lower castes feel that it is acceptable for an entire family to consume alcohol because of their religious and cultural traditions:

And the lower caste things like… Wait, they do not feel it is a problem. Like…

they feel like this is our tradition. Like in that culture, like a husband is drinking,

the wife is drinking, children are drinking, and they don't see it as a problem…

In contrast, he asserted that the higher castes are more likely to engage in problem drinking than the lower castes. He explained 'Because when these higher caste drink…

They do not drink like they are not going from gradually like they are going in the peak'.

Our respondents also reported that people belonging to the upper castes were more likely to be treated than people belonging to the lower castes 'Mostly [people] from, the higher caste they're getting treatment'.

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A focus group conducted with a community health center confirmed the belief that it is unacceptable for higher castes to consume alcohol. Our respondents indicated that people belonging to the Brahmin caste are teachers of spirituality, and it is disgraceful for them to consume alcohol:

I guess it comes under caste systems. Yeah, like the Brahmins, that's part of the caste system. This is supposed to be high caste, like, they're supposed to be close to… I guess. Like they're supposed to be like teachers of spirituality... So, they're not supposed to drink.

Focus group members support the idea that alcohol is stigmatized within the

Bhutanese/Nepali community. As noted by community members, the higher castes are not permitted to consume alcohol, which is perceived as tainting their spiritual purity

(Dhital et al. 2001; Subedi 2011).

DISCUSSION

This study examined how the caste system influences barriers to integration and access to social services in the resettled Bhutanese/Nepali community. Findings indicate that most community members are reluctant to seek treatment related to substance abuse or mental health. Regardless of caste, community members often described mentally ill people as a bad person or someone who could not be trusted. Indeed, prior research indicates that community members often describe individuals with mental illness as being violent or someone they cannot maintain social connections with other people (Shannon et al. 2015). Other scholars indicate that substance abuse is highly stigmatized, and members of the upper castes may encounter additional stigma for using alcohol (Dhital et al. 2001). A greater number of lower caste people described being separated from family members, presenting them with barriers to maintaining social networks as well as a new source of stress. This finding is consistent with studies finding that resettled community

120 members were estranged from family members who were resettled into different states or countries (Dutton 2011; Lundström and den Uyl 2010).

Language is another barrier to integration encountered by members of the

Bhutanese/ Nepali community. Some participants described that they were dependent on their children, who command a deeper understanding of the English language. Indeed, several studies have found that resettled refugees are often dependent on their children for making medical appointments and interacting with providers (Dutton 2011). These results also suggest that parents encounter additional stressors when their children use their mastery of the English language to take advantage of them. Our respondents indicate that children may sometimes call the police, and their parents cannot interact with law enforcement due to their inability to speak English. These findings also demonstrate that lower caste community members may struggle to articulate their symptoms to medical professionals. Members of the higher castes are sometimes provided an interpreter, but encounter added stress if they feel their words are not adequately being interpreted from Nepali to English. As noted in chapter three, members of the higher castes also have more cultural health capital and likely have more favorable interactions with providers than lower castes.

This research also reveals that the Bhutanese/Nepali community members also encountered several economic barriers to integration and healthcare. Members of the lower castes often encountered more economic barriers than people in the higher castes.

For instance, a few members of lower castes respondents described being unable to find work upon resettlement and moved to Akron because they believed there would be more job opportunities. However, members of all castes reported difficulties finding entry-level

121 employment in the Akron area. When community members find entry-level work, it is physically demanding, lacking autonomy, and unfulfilling (Dhital et al. 2001; Lundström and den Uyl 2010). Findings demonstrate that a few lower castes reported practicing a skilled trade but could not find work because their degrees were not recognized in their host society. Some studies indicate that higher castes had access to more resources, which enabled them to regain educational credentials upon resettlement (Ott 2013). A few upper-caste community members asserted that they were resettled into affluent areas, and local agencies found stable employment.

Additionally, a majority of provider interviews that the caste system presented community members with barriers to treatment. Members of a focus group conducted at a social services agency asserted that community members would not want to be treated by people belonging to lower castes. Numerous studies have found that the higher castes may avoid social interactions with lower castes (Gellner 2007; Patel 2012; Subedi

2016b). A resettlement agency provider also asserted that alcohol consumption is stigmatized for members of the upper castes but not members belonging to the lower castes. On the one hand, the lower castes engage in alcohol use during religious ceremonies, weddings, funerals, and births (Dhital et al. 2001). On the other hand, people from higher castes are not permitted to drink because they are viewed as being spiritually pure (Dhital et al. 2001). This result suggests that the stigma associated with alcohol consumption may push community members of higher castes into substance abuse treatment.

There are several limitations associated with this project. Interviews with community members were often conducted in Nepali and interpreted into English. The

122 interpretations we were provided with may not accurately reflect the participants' thoughts or feelings. Further, our interpreter also worked as a Christian pastor who is well known in the community. His presence may have caused community members to respond in a socially desirable way when asked about topics associated with substance abuse or mental health. Another concern was we were unable to gain entrée into interviews with important providers who interacted with the community including hospitals, law enforcement, and doctors' offices. We could have collected more demographic data on providers including respondent age and race. Data for this project was also collected as part of a larger project focused on substance use in the Bhutanese/Nepali community. The interviews were not intended to assess the caste system's effects on barriers to integration and access to social services. However, the caste system is a sensitive topic, and other data collection methods might struggle to represent the diversity of the Bhutanese/Nepali community accurately.

Conclusion

These results indicate that the lower castes may perceive more barriers to integration and access to care associated with finding meaningful employment, rebuilding social networks. This finding is consistent with studies indicating resettled

Bhutanese/Nepali often report working in jobs they find unfulfilling or encounter difficulty finding work (Dutton 2011; Gurung 2019; Lundström and den Uyl 2010). This project also dovetails with literature finding that community members may struggle to develop social connections due to being resettled in dangerous neighborhoods or struggling to master English (Dutton 2011; Kohrt et al. 2012; Lundström and den Uyl

2010). Another key finding is that mental health is highly stigmatized for most

123 community members, which may prevent community members from seeking treatment.

Regardless of caste, most community members indicated that English is frequently a barrier to treatment. For example, some respondents indicated that they could accurately describe symptoms to healthcare professionals. Ultimately, these results expand on the acculturation stress literature by illuminating the caste system's impact on integration and access to social services.

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CHAPTER V

CULTURALLY COMPETENT MENTAL HEALTH TREATMENT

Bhutanese/Nepali community members have a different social construction of mental health than individuals living in western societies. People of Bhutanese/Nepali descent experience several acculturation stressors such as finding a job, learning the

English language, denial of citizenship, and navigating their communities (Ager and

Strang 2008; Benson et al. 2012; Dutton 2011; Miller and Rasco 2004). Encounters with these stressors have mental health consequences such as anxiety, depression, and suicide

(Ao et al. 2012; Cochran et al. 2013; Schininà et al. 2011). Like other Asian populations, depressive symptoms in the Bhutanese/Nepali community often manifest as a feeling of physical pain (Shannon et al. 2015). Community members also describe feelings of sadness as a darkness that prevents community members from interacting with others

(Patel 2012; Shannon et al. 2015; Van Ommeren et al. 2001). Mental health conditions are stigmatized within the Bhutanese/Nepali community, which may exacerbate existing stressors and barriers to care (Kohrt et al. 2012; Patel 2012; Shannon et al. 2015).

There are a variety of community-based treatments that can be employed in refugee communities, which provide community members with a place to address concerns related to mental health and interact with others. English as a second language

(ESL) courses can be used to provide refugees with a safe space to talk about mental

125 health and develop coping strategies (Dutton 2011; Miller and Rasco 2004). Community gardening offers another avenue for culturally mental health treatment, enabling refugees to reconnect with their society of origin and provides them with more opportunities to interact with others (Hartwig and Mason 2016; Hinton 2016). Bhutanese refugees seldom use mental health treatment programs because they fear encountering stigma from other

Bhutanese/Nepali community members (Kohrt et al. 2012; Shannon et al. 2015). This chapter aims to uncover strategies to improve coping using in-depth interviews conducted with 100 community members and 20 providers. Further, this dissertation also sheds light on how the caste system shapes coping and if different strategies need to be employed to provide care for the diverse Bhutanese/Nepali community.

LITERATURE REVIEW

Bhutanese/Nepali Conceptualization of Mental Health

Research conducted by Kohrt et al. (2012) indicates that Bhutanese/Nepali view health as being connected to four components of the self, which consist of the physical body (jiu), spirit (saato), heart-mind (man), and brain-mind (dimaag). Prior research suggests that mental health is primarily concerned with the participants' heart-mind, which is used to describe a person's emotional states (Chase and Bhattarai 2013; Kohrt et al. 2012). For example, a heart-mind condition could manifest itself as feelings of depression or anxiety (Kohrt et al. 2012). The brain-mind can be used to understand mental health conditions associated with acts of deviance (Chase and Bhattarai 2013;

Kohrt et al. 2012; Schininà et al. 2011). For example, Kohrt et al. (2012) assert that an individual who violated the gender norms associated with Bhutanese society would have a mental illness related to the brain-mind. Several studies indicate that family members

126 describe Bhutanese/Nepali refugees who commit suicide as having problems in either the heart-mind or brain-mind components of the self (Kohrt et al. 2012; Schininà et al. 2011).

Members of the Bhutanese community often describe mental illness as darkness, which prevents them from interacting with other people (Benson et al. 2012; Shannon et al. 2015). A report conducted by Shannon et al., (2015) indicates that refugees experiencing these feelings avoided talking to other people and reported stigma from other community members. People with a mental health condition are stigmatized as being violent or murderous (Shannon et al. 2015). Other studies have found mental health conditions in the Bhutanese community often manifest themselves as psychosomatic symptoms (Kohrt et al. 2009; Patel 2012; Van Ommeren et al. 2001). Like other Asian populations, resettled Bhutanese/Nepali refugees often experience depressive symptoms including pain and stomach ulcers (Kohrt et al. 2009; Patel 2012).

The Bhutanese construction of mental health conditions is also rooted in Hindu religious traditions. For example, numerous studies suggest that members of the

Bhutanese community view an individual as part of a larger social body rather than autonomy (Benson et al. 2012; Dutton 2011; Hodge 2004). These cultural beliefs may make western forms of counseling ineffective forms of treatment centered on individualism. For example, western psychiatry is founded on the idea that the self exists independently from other entities, which opposes the Hindu values that everything is interconnected (Dutton 2011; Hodge 2004). Prior research suggests that these forms of treatment may further exacerbate the stressors experienced by resettled refugees struggling to acculturate to western societies (Benson et al. 2012; Miller et al. 2002;

Schininà et al. 2011). Effective mental health interventions in the Bhutanese community

127 should also include an interpersonal component, which encourages providers to take a culturally competent approach to treat mental health conditions (Dutton 2011; Miller and

Rasco 2004).

Most refugee resettlement agencies offer programming to incoming refugees, which helps them navigate their communities. Agencies provide newly settled refugees with orientation services, housing, English courses, and employment services (Hoellerer

2013; Ott 2013). Refugees receiving services from local agencies are also provided with caseworkers responsible for connecting individuals to resources in their communities (Ott

2013). However, caseworker positions are being cut, and resettlement programs increasingly operate with inadequate funding (Dutton 2011; Hoellerer 2013; Ott 2013).

Indeed, newly resettled refugees report feeling overwhelmed by the process of migrating to their new host societies and being given inadequate access to social services (Dutton

2011; Hoellerer 2013). In some communities, new arrivals struggle to navigate resources to their neighborhoods and often depend on more experienced community members for help (Hoellerer 2013).

Community Members and Stressors

Refugees integrating into their host societies encounter a range of stressful life events and persisting strains. Forcibly displaced Bhutanese refugees frequently face stressors during the acculturation process associated with learning the English language, finding stable employment, and navigating their host societies (Benson et al. 2012;

Dutton 2011; Hoellerer 2013; Strang and Ager 2010). The Stress Process Model (SPM) indicates that traumatic experiences harm mental health and produce feelings of uncertainty (Pearlin et al. 1981; Thoits 1995). Indeed, initial sources of stress can become

128 persisting life strains if they remain unresolved (Pearlin et al. 1981). Resettled refugees who are unable to find stable employment report having a negative self-concept and feelings of failure. The inability to integrate and persisting acculturation stress is associated with suicide and depressive symptoms (Ao et al. 2012; Hagaman et al. 2016;

Vonnahme et al. 2015). The SPM further indicates that encounters with stressful life events can intensify old problems or preexisting trauma (Ferraro and Wilkinson 2013;

Pearlin et al. 1981; Thoits 1995).

Certainly, Bhutanese refugees also encountered traumatic experiences that often persist upon resettlement into their host societies. Before their flight from Bhutan, refugees encountered sources of stress including violence, torture, and imprisonment

(Dutton 2011; Hutt 2005; Rizal 2004). Many of these initial sources of stress became chronic stressors during their time in refugee camps located in the Jhapa district of Nepal, which undermined control for refugees. Refugees living in camps reported feelings of hopelessness, which is fostered by the inability to work, feelings of uncertainty, and a loss of cultural identity (Patel 2012; Shannon et al. 2015). Numerous studies have found that rape and human trafficking were commonplace in the camps (Dutton 2011;

Lundström and den Uyl 2010). Refugees indicate that encounters with sexual violence become a life strain because women frequently report feelings of shame and a loss of social status (Lundström and den Uyl 2010; Shannon et al. 2015). Bhutanese refugees were forced to contend with these harsh conditions for decades and had little control over these stressful life events.

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Social Support and Coping

Pearlin et al. (1981) assert that social support functions as a buffer against sources of social stress. Prior scholarship argues that people who perceive feelings of support from friends and families are less likely to experience depressive symptoms (Thoits

1995). Resettled Bhutanese/Nepali refugees rely on community organizations and resettlement agencies for social support and resources to navigate their host societies

(Halsouet 2013; Ott 2011; Pace et al. 2015). English as a Second Language (ESL) provides refugees with a safe space to discuss mental health conditions and build relationships with other people (Dutton 2011; Miller and Rasco 2004). Membership in organizations such as temples, churches, and community gardens also provide resettled refugees with the opportunity to rebuild connections with other people (Hartwig and

Mason 2016; Woods and Pulla 2016). However, lower castes may struggle to rebuild social networks due to experiencing stigma from people belonging to the higher castes

(Patel 2012; Subedi 2016b).

Coping mechanisms in the SPM describe behavioral or cognitive efforts to rescue sources of distress and minimize life strains' impact (Pearlin et al. 1981; Thoits 1995).

People use coping mechanisms to modify stressors and manage stressful symptoms

(Pearlin et al. 1981). Resettlement agencies are responsible for helping new community members find housing, employment, and healthcare (Ager and Strang 2008; Hoellerer

2013). There is evidence that English courses could be used as a safe space to discuss mental health and identify community resources (Dutton 2011; Miller and Rasco 2004).

Religion is another mechanism used by resettled refugees, and membership in a religious community helps refugees rebuild social capital, and prayer can be used as a coping

130 strategy (Woods and Pulla 2016). Finally, community gardening programs provide refugees with a way to preserve their culture, practice traditional rituals, and prepare foods associated with their society of origin (Hartwig and Mason 2016; Hinton 2016).

English as a Second Language and Coping

To develop a culturally competent mental health treatment program, English as a

Second Language (ESL) courses provide participants with a safe space to integrate with a new culture (Dutton 2011; Strang and Ager 2010). The ESL classroom should teach refugees strategies to manage stressors and provide participants with a supportive environment (Dutton 2011; Miller and Rasco 2004). After one year, refugees should have attained enough language skills to navigate their communities (Hoellerer 2013).

However, there is evidence that resettled refugees often do not experience a smooth transition to their host societies due to acculturation stressors (Ager and Strang 2008;

Hoellerer 2013). For example, Miller et al. (2002) have found that refugees exposed to traumatic life events may struggle to learn English due to difficulties concentrating, impairments in memory, and depressive symptoms.

Prior research suggests that ESL classrooms should be used to assist resettled refugees with the acculturation process (Dutton 2011; Miller and Rasco 2004). For instance, prior research indicates that courses should work to expose participants to local resources and work to help them navigate their communities (Dutton 2011; Hoellerer

2013; Miller and Rasco 2004). There is evidence that creating a safe space in ESL courses functions as a valuable source of social support (Dutton 2011; Miller and Rasco

2004). For instance, ESL classrooms can teach resettled refugees to identify mental health symptoms and avenues for treatment (Dutton 2011). Thoits (1995) has found that

131 membership in an organization can buffer individuals against sources of stress. The use of ESL classes also functions as a coping mechanism because they link resettled refugees to resources that reduce stressors.

There is also substantial evidence that mastering English would help refugees contend with acculturation stressors and other barriers to care (Dutton 2011; Miller and

Rasco 2004; Strang and Ager 2010). Learning English improves access to employment, housing, and healthcare (Ager and Strang 2008; Dutton 2011). Lacking resources also functions as a source of stress (Pearlin et al. 1981; Thoits 1995), which may impair lower caste members' ability to cope with stress. These findings may suggest that members of the lower castes may have fewer resources to cope with sources of stress than individuals belonging to higher castes (Patel 2012; Subedi 2016b). In general, additional ESL courses would improve coping in the Bhutanese/Nepali community.

Religious Beliefs and Coping

Bhutanese community members turn to religion as a coping mechanism to deal with feelings of anxiety and depression. Refugees reported turning to a higher power because they believed no one else would help them except for a higher power (Woods and Pulla 2016). Using a survey of resettled Bhutanese refugees, Benson et al. (2012) find that community members who used religion as a coping mechanism were less likely to report acculturation stress than refugees who could not practice their religion. Belief in a higher power further provides resettled refugees with feelings of strength, hope, and resilience (Benson et al. 2012; Dutton 2011; Woods and Pulla 2016). Hindu refugees described believing in Karma, which is the notion that individuals should try to do good regardless of their circumstances (Hodge 2004; Woods and Pulla 2016). Several studies

132 also indicate that practicing religious ceremonies also provides Bhutanese of Nepali descent with peace and a sense of control (Dutton 2011; Halsouet 2013; Hodge 2004).

Pearlin et al. (1981) remind us that the feeling of being in control provides a buffer against sources of stress.

There is substantial evidence that continuing to practice religion provides refugees with feelings of social support (Benson et al. 2012; Halsouet 2013; Hodge 2004).

Bhutanese of Nepali descent describe the community as central to their well-being and construct their self-concepts as dependent on other people (Dutton 2011; Halsouet 2013;

Hodge 2004). Having a positive self-concept and feelings of social support provide a buffer against the development of depressive symptoms (Ferraro and Wilkinson 2013;

Pearlin et al. 1981; Thoits 2011). The ability to practice religion allows refugees to feel connected with earlier generations and preserves connections to Bhutan and Nepal

(Halsouet 2013; Woods and Pulla 2016). According to Woods and Pulla (2016), refugees also used religion to rebuild severed connections with other Bhutanese community members. Refugees separated from family members view their new religious communities as a source of social support (Benson et al. 2012; Halsouet 2013; Woods and Pulla 2016).

Before resettlement, most of the Southern Bhutanese practiced Hinduism, which has influenced social norms and the organization of the caste system and society (Benson et al. 2012; Dutton 2011; Hodge 2004). The inability to practice religious beliefs is a life strain that deprives resettled refugees of social support and hampers the ability to cope with acculturation stress (Benson et al. 2012; Halsouet 2013). Resettled refugees report feelings of distress when they cannot practice their religion at a Hindu temple, perform

133 traditional ceremonies, and maintain a vegetarian diet (Benson et al. 2012; Dutton 2011;

Hodge 2004). Many refugee communities also lacked a brahmin priest who was not given priority during resettlement. These priests are the only people qualified to perform religious rituals (Halsouet 2013). On the one hand, younger members of the community are increasingly converting to Christianity as a coping mechanism (Halsouet 2013), but elderly Bhutanese still attempt to subscribe to Hinduism's traditions (Halsouet 2013; Patel

2012).

Although resettled Bhutanese refugees encounter several barriers to practicing

Hinduism, they still find ways to exercise their spiritual beliefs (Dutton 2011; Halsouet

2013; Patel 2012). For instance, resettled Bhutanese of Nepali descent describe using

Indian temples to maintain their connections to Hinduism. However, Indian worshipers often practiced different religious ceremonies, which is not ideal for most

Bhutanese/Nepali refugees (Halsouet 2013). Bhutanese/Nepali community members report that having a temple still gives them the ability to connect with other temple members, meet religious leaders, and participate in religious ceremonies (Dutton 2011;

Halsouet 2013; Hodge 2004). Hindu refugees report conducting daily prayers, which did not require a brahmin priest's guidance18 (Halsouet 2013; Hodge 2004; Patel 2012). As noted in earlier chapters, most Hindu Bhutanese/Nepali community members performed rituals associated with the caste system. Individuals from higher castes would not be permitted to enter the residence of people belonging to lower castes or accept meals prepared by them (Halsouet 2013; Subedi 2016b). These findings further stress that the

18 At dawn and dusk Hindu refugees described performing a pūjā, which involved a bath and prayers to the gods (Halsouet 2013). During the day Hindus also performed tika. These rites included singing songs, reciting passages from the Bhagavad-Gītā, and offering food to the gods (Halsouet 2013).

134 higher castes may be reluctant to form social networks including people belonging to the lower castes.

Conversion to Christianity is another way refugees use their religious beliefs to cope (Kohrt et al. 2012; Patel 2012). Practicing Christianity allowed resettled refugees to overcome many of the barriers Hindus encountered during the resettlement process

(Kohrt et al. 2012; Patel 2012). For example, Christians could pray without priests and do not need to worship at a temple (Kohrt et al. 2012). In-depth interviews conducted by

Patel (2012) have found that converting to Christianity provided members of lower castes with a sense of relief because it allowed them to distance themselves from stressors such as discrimination from members of higher castes. Halsouet (2013) has found that resettled refugees often formed churches upon resettlement, which served Bhutanese of

Nepali descent exclusively. Many of the social services received by refugees upon resettlement were managed by Christian organizations that linked refugees to their community's resources (Dutton 2011; Halsouet 2013).

A smaller portion of resettled Bhutanese refugees practiced Kirat, referring to people from Eastern Nepal (Rai et al. 2009; Thapa 2010). People practicing this religion worship their ancestors and many local deities associated with nature (Rai 2012).

Followers performed rituals based on their religious text called the Mundum, which provides information on conducting ritual chants and prayers (Rai 2012; Rai et al. 2009).

However, the Mundum also refers to an oral tradition where religious beliefs are passed down from community elders to younger generations (Rai 2012; Rai et al. 2009). These traditions also inform several religious rituals associated with birth, marriage, and death

(Rai 2012). Prior research reminds us that clinging to these religious traditions can

135 function as a coping mechanism (Scudder and Colson 1982). Rai (2012) indicates that practitioners of Kirat religious beliefs also plan events such as dances, ritual chants, and music festivals. These events may provide resettled refugees with opportunities to rebuild their social networks, and numerous studies have found social support provides a buffer against the development of mental illness (Ferraro and Wilkinson 2013; Pearlin et al.

1981; Thoits 2011).

A small amount of Nepali/Bhutanese practiced Buddhism upon resettlement.

Before resettlement, most Buddhists lived in small agrarian communities with other practitioners of their religion (Evans 2010; Pulla 2016). There is substantial evidence that

Buddhist meditation and ceremonies provide Bhutanese/Nepali refugees with a mechanism to cope with stressors related to their flight from Bhutan and new sources of acculturation stress (Dutton 2011; Woods and Pulla 2016). Ultimately, resettled

Bhutanese refugees frequently turn to their religion to cope with stressors (Benson et al.

2012; Hodge 2004; Woods and Pulla 2016).

Sampling and Coding Procedure

Snowball sampling is employed to recruit members of the community to participate in our study. A member of the research team interviewed individuals who agreed to participate in the study. We also employed theoretical sampling because it allowed our team to reach subgroups of the community member and provider samples

(Charmaz 2008; Corbin and Strauss 1990). Santa targeted community members based on gender, caste, and religion. Likewise, we ensured our sample included the major resettlement agencies in Akron, mental health clinics, and law enforcement officers.

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Using theoretical sampling ensures our team can make meaningful comparisons across each group included in the sample (Corbin and Strauss 1990; Glaser and Strauss 1967).

This chapter focuses on themes coded from the portion of the interview guides that centered on developing a culturally competent mental health treatment program. Data were managed and coded using NVivo 12 Pro. Our team used open coding to code the first five transcripts. These interviews were analyzed line by line and began to identify themes from the data. To ensure reliability, our team met to develop a codebook based on preliminary themes before proceeding. Any discrepancies in coding were discussed at weekly team meetings. After completing open coding, our team analyzed the interviews using focused coding, which enabled us to inspect themes that participants frequently discussed19.

Community Gardening and Coping

Before resettlement, the Southern Bhutanese belonged to an agrarian society, and resettled refugees often worked as farmers in some capacity (Evans 2010). According to

Hutt (2005), Bhutanese of Nepali descent were invited by the government to settle in

Bhutan and develop the country's southern regions. Bhutan's southern portion was mostly undeveloped and viewed as uninhabitable by the Northern Bhutanese (Evans 2010;

Hinton 2016). During the 1800s, Nepali migrants settled on the countries southern borders developing tight-knit farming communities. The Southern Bhutanese also supplied the rest of the country with food, and agriculture composed most of the nation's

19 All participant information is stored in a password-protected cloud-based server, which could only be accessed by a research team member. Respondents could also contact a member of the research team and have their information destroyed.

137 economy (Hutt 2005). Research conducted by Hinton (2016) has found that Bhutanese refugees were more likely than any other refugee group to utilize community gardens.

There is some evidence that community gardening may help resettled refugees contend with the resettlement process and preserves the culture from their society of origin. Numerous studies define community gardens as spaces where plants are grown in a communal environment (Gerber et al. 2017; Hartwig and Mason 2016; Hinton 2016). A series of in-depth interviews conducted by Gerber (2017) demonstrates that community gardens reminded Bhutanese refugees of the green fields back home. Indeed, working in a community garden allows refugees to recall working in Bhutan's sensory experiences

(Gerber et al. 2017; Hartwig and Mason 2016; Hinton 2016). Research conducted by

Hinton (2016) indicates that refugees further preserve their identities through growing crops and using farming techniques associated with their society of origin. Bhutanese culture is further maintained because community gardens allow refugees to prepare foods and practice rituals related to their society of origin (Benson et al. 2012; Hinton 2016;

Niroula and Singh 2015).

Interviewees reported that community gardening helped them connect with other people and described stronger feelings of social support (Gerber et al. 2017). Resettled refugees who contributed to a community garden frequently interact with other people and rebuild social ties (Gerber et al. 2017; Hartwig and Mason 2016). For example,

Bhutanese refugees who worked in a community garden reported gardening as a group and also frequently shared meals (Hartwig and Mason 2016). According to Hinton

(2016), older adults benefit from using community gardens as a coping mechanism because they are prone to developing feelings of isolation. The use of community

138 gardening also strengthens social networks by providing refugees with opportunities to practice English and speak their native languages (Hartwig and Mason 2016; Hinton

2016). Several studies indicate that having a large social network or joining a group provides a buffer against depressive symptoms (Pearlin et al. 1981; Thoits 2011).

There is also evidence that community gardening can function as a coping mechanism to buffer refugees against the development of mental health conditions

(Gerber et al. 2017; Hartwig and Mason 2016; Hinton 2016). Community gardens ameliorate depressive symptoms, feelings of anxiety, and low self-esteem (Gerber et al.

2017; Hartwig and Mason 2016; Hinton 2016). Resettled refugees believed community gardening offered them a way to relieve feelings of depression and further bolstered self- esteem (Hartwig and Mason 2016). Hinton (2016) has found that gardening provides unemployed Bhutanese males with feelings of self-worth, which may help reduce suicides in these men who are at high risk of taking their lives. Bhutanese men are socialized to lead their families, but this identity is undermined when resettled men cannot find work or provide for their families (Hagaman et al. 2016). Research conducted by Hartwig and Mason (2016) asserts that women will work in the gardens when they feel sad and report that gardening helps them cope with depressive symptoms. This project strives to understand how caste inequalities might influence gardening as a coping mechanism in the Bhutanese/Nepali community.

The current study expands the integration and the SPM literature by examining coping mechanisms utilized by social service providers and the Bhutanese community.

Further, this project illuminates differences in coping based on respondent caste. The chapter also offers insight into the differences between providers and the communities

139 they serve. Data analysis is guided by the research question "How can providers and community members improve the mental health and coping mechanisms of Bhutanese

Refugees". This research question is addressed by using in-depth interviews conducted with 100 members of the Bhutanese community and 20 interviews with social service providers. The data was collected as part of a larger project called the Bhutanese Refugee

Substance Abuse Study (BRSAP), which includes several questions on coping, mental health, and substance abuse treatment.

METHODS

The interviews used for this study come from the larger project (BRSAP), which was used to assess problem drinking and solutions in the Bhutanese/Nepali community20.

I use this data to address research questions focused on stratification and health. This study employs 20 in-depth interviews conducted with social service providers. The questions providers answered were centered on the work, the services provided to the

Bhutanese community, the use of alcohol in the Bhutanese community, and the treatment of alcohol-related conditions. Additionally, two focus groups were conducted with local agencies that concentrated on treating mental health conditions. Providers who completed focus groups answered questions based on the interview guide administered to the other participants.

20 Dr. Marnie Watson, anthropologist, and research associate at the University of Akron, led the Bhutanese Refugee Substance Abuse Study data collection. There were five research assistants from the University of Akron including Jimmy Carter, Nuha Alshabani, Julian Curet, Vyshu Ramini, and myself. Research assistants who worked on the project received formal training in social science such as psychology, anthropology, or sociology. The International Institute of Akron hired Santa Gajmere to be our interpreter. Santa was responsible for helping participants complete informed consent forms, translating interviews, recruiting participants, and providing a debriefing. Santa also ensured the research team understood the social norms to follow when interacting with community members.

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In-depth interviews were also conducted with 100 members of the Bhutanese community who were of Nepali descent. Interview questions focused primarily on the participants' background, use of social services, and use of alcohol in the community. The last section of the interview guide concentrated on mental health treatment related to alcohol disorders as well as alcohol-related disorders.

Community Member Characteristics

Community members were composed of 55 men and 45 women. The average age of the participants is 40 years old. Regarding religion, 30 participants believed in

Christianity, 34 individuals were Hindu, 23 interviewees practiced Kirat, and 13 respondents were Buddhists. Exactly 47 members of the upper castes completed interviews. There were 23 Brahmins and 24 Chhatriya. There were 53 members of the remaining castes. This group consisted of 30 Vaisya and 23 Shudra21.

Table 11: Summary Statistics Demographic Mean/Percent

Gender Male 55% Female 45% Age 40

Religion Christian 30% Hindu 34% Kirat 23% Buddhist 13% Caste Brahmin 23% Chhatriya 24% Vaisya 30% Shudra 23% Total 100%

21 Bhutan follows the caste system, and the highest castes are the Brahmin and Chhatriya. Members of these castes work in prestigious occupations including academia, priests, and administration (Gellner 2007). The lower castes are the Vaisya and the Shudra. Members of these castes work as merchants and laborers (Gellner 2007; Subedi 2016a).

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Provider Characteristics

Men composed roughly 40 percent of the sample, and women composed nearly

60 percent. Seven providers worked at a social services agency centered on offering clients a range of services including healthcare, resettlement, and employment. Six providers worked for a community health center. Four respondents worked at local resettlement agencies, which helped refugees acculturate to their host society. Two providers worked at behavioral health centers that provided treatment for mental health disorders or conditions connected to substance abuse. Just one participant worked as a law enforcement resources officer who worked directly with Bhutanese/Nepali community members.

Table 12: Provider Characteristics Demographic Frequency Percent Organization Type Behavioral Health Services 2 10% Community Health Center 6 30% Law Enforcement 1 5% Resettlement Agency 4 20% Social Services 7 35% Gender Male 8 40% Female 12 60%

COMMUNITY MEMBER RESULTS

Accounts from members of the Nepali/Bhutanese community and local social services providers indicate that several culturally competent treatments can be developed to improve coping and combat problem drinking. I identify three methods of improving coping in the Nepali Bhutanese community: expanding educational programming, using religion as a coping mechanism, and using community gardening.

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Expanded Educational Programming

There were 44 of 100 community members who supported the expansion of educational programming. 25 respondents (57 percent) were members of the Shudra or

Vaisya castes. There were 19 participants (43 percent) who were members of the

Brahmin or Chattriya castes who believed educational programs would help solve problem drinking.

Members of the Shudra and Vaisya castes suggested that local agencies expand their programming to offer English, citizenship, and vocational training courses. One

Vaisya man (age 38) explained:

Different kinds of programs like language classes, like teaching them different uh, vocational type of, type of education; if they have that kind of program, they will definitely control [their use of alcohol]. So above all, we need help, uh, for citizenship classes. So, in our community, many people do not get citizenship.

This respondent further stresses the importance of these classes for helping others gain access to citizenship. He continued: "So after seven years, all the benefits whatever they have been getting; If they do not pass their citizenship exam everything goes away, and they will commit suicide".

Members of the Chattriya and Brahmin castes also indicated that educational programs would help community members cope with stressors. Several respondents also suggested that English courses are crucial for assisting Nepali/Bhutanese contend with stress. One 27-year-old Chattriya man stated:

Education is a solution; educational programs are down in our community. The main thing is community members cannot speak English. They become depressed, and they start drinking because the language barrier is such a problem. This respondent underscores that community members need greater access to educational programming, which would help them overcome many of the obstacles associated with

143 navigating their communities. Indeed, several studies have identified the inability to speak English as a barrier to treatment and maintaining access to social services (Dutton

2011; Hodge 2004; Ott 2013).

A few community members from each caste indicated that the community also needed to offer educational programming to teenagers. Respondents suggested that teenagers needed more activities to "divert their mind" from stressors through coping mechanisms such as sports or extracurricular activities. A Vaisya man (age 54) stated,

"Young people like organized sports. And some of them, a musical program or a reading program". One 30-year-old Brahmin man stressed that education programs need to be developed to help adolescence prepare for their futures.

They don’t know the system… how to go to college. We need to encourage them

if you are busy in something good… you don’t do abuse alcohol. But if you are

free, if you are not initiative with the future, or if you are not concentrating, then

you will engage in substance abuse. Young people need to be also give aware

about how to go to college and how to make their future. They need to show the

opportunity for their life.

This respondent demonstrates that younger people could also benefit from programs designed for them rather than programming offered for older generations. Indeed, several studies indicate that teenagers command a more substantial mastery of English than their parents (Dutton 2011; Gurung 2019). These findings may suggest that young people do not contend with the same stressors as previous generations.

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Use of Religion to Cope

There were 38 of 100 respondents who reported that religion functioned as a coping mechanism. 20 respondents (53 percent) were members of the lower castes (11

Shudra and 9 Vaisya), and the other 18 (47 percent) belonged to the upper castes (8

Chhatriya and 10 Brahmin).

Members of every caste believed that listening to religious leaders or practicing beliefs provided them with coping mechanisms. One Vaisya man (age 41) stated that religious leaders could help community members contend with stress and problem drinking through counseling or advice. He explained:

Some community members may get improved because of advice and counseling. Just like me uh, the feeling of self-consciousness regarding life. Um, thinking that, ok this is not that thing that I must drink. This is how my life must be. If we start thinking in that way, definitely he or she will get corrected.

Members of every caste reported that religious leaders could help community members cope with stressors by providing their religious communities with counseling. One 52- year-old brahmin man reported: "I have the guru who is here, according to his teaching and according to his vision… He advises people not to take alcohol or other substances".

Another Brahmin man (age 52) asserted that religious beliefs were responsible for reducing sources of stress. He states that religion gives worshipers knowledge about their purpose in life:

What I feel, the solution for reducing stress is knowledge about the creator, the one who created us. If we have the knowledge about those kinds of things, like knowledge about the one who has created, why he created, the reason for the creation; so, if we have that kind of like intense, that internal knowledge and wisdom regarding the creator and his like um, whatever the message that he has given, I think that also will help us to reduce the stress to that knowledge.

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This community member's ideas are consistent with studies finding that belief in a higher power strengthens feelings of control, hope, and resilience (Benson et al. 2012; Dutton

2011; Woods and Pulla 2016). Members of lower castes seldom discussed beliefs as a coping mechanism, but a few discussed engaging in prayers or religious rituals. One

Vaisya man (age 38) stated: "After reading and going through the lines of the Bible, I totally stopped! Now, I am never drunk".

Community members also discussed the diversity of the Nepali Bhutanese community who practice a variety of different religions. One man from the Chhatriya caste (age 60) explained that each religious community should train worshipers to cope with sources of stress and avoid the use of alcohol. His response stresses that the Nepali

Bhutanese community is very diverse, each group has a different set of beliefs, and may have a different understanding of how to cope with stressors:

If a person goes to this community, may not follow the idea of Christian group this another group, like Hindu, there’s a Hindu group if a Buddhist person comes here and they start doing the training work, during that time Hindu men may think oh, okay okay the group of people influencing us isn't that just solve that problem, Hindu people, Hindu leaders but same knowledge same concept, everything, the people influencing the same, Buddhist people influencing, Christian people influencing the same way Kirat people influencing in the same way or the same topic same subject matter same knowledge so if they if we go that way I think that will be easy and that will be effective instead of creating disputes. I think that will solve because they will think our leader has taught the same thing. Our participant's response also indicates that members of each religious group should receive the same training about mental health and substance use. Later in the interview, he states that each religious leader could implement the same program to better meet the community's needs. "We [Community members] learned the same thing so that way we can change their mentality and the heart of every person". However, his response further

146 suggests that listening to a different religious leader would create disputes within the community.

Members of the lower castes echoed the sentiments that mental health messages need to be disseminated through each of the religions in the community. One 36-year-old

Shudra man explained:

So, if one group of people are talking about Christianity, another group they don't like that message… They have their faith. It is not good; you know to talk all about the other beliefs.

This respondent also expressed that he once assisted with a Hindu program open to everyone and invited local pastor "nobody came, but the few who attended believed it was a cultural program".

Conversion to Christianity

There were 15 community members who described conversion to Christianity helped them cope with stress. Ten of these respondents (66 percent) were members of the lower castes (Shudra and Vaisya), and the remaining five (44 percent) belonged to the

Chhatriya caste. Although eight Brahmin respondents practiced Christianity, there were no Brahmin caste members who explained their conversion functioned as a coping mechanism. Members from the highest castes may still practice Hindu traditions associated with their position (Hodge 2004; Woods and Pulla 2016).

An interview conducted with a Christian member of the Vaisya caste (age 54) supports the idea that the lower castes might convert to Christianity. He explained how finding Christ changed his life and encouraged him to avoid using substances to cope.

Dhital et al. (2001) remind us that alcohol is sometimes used in religious ceremonies, and people belonging to lower castes are permitted to use alcohol.

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I come from the same uh, family background because my forefathers used to practice the same thing. But after I see, and after I knew the real-life, Christ… and after I knew Christ, I left everything, and my life can truly completely changed.

Our community member stresses that he left everything practiced by his ancestors and described his conversion to Christianity as life changing. Patel (2012) asserts that lower castes encountered acts of discrimination from people belonging to the upper castes and may convert to Christianity to avoid these negative stereotypes.

A few members of the upper castes reported that practicing Christianity may provide them with other coping mechanisms. One middle-aged Chhatriya man (49 years old) explained that an older woman in the community helped him convert to Christianity, which would also provide other community members with an example:

She advised me to go to church every Sunday or every time. So, I thought this is my time for me to turn. Once you get corrected, you have a good testimony. You can share the good testimony to so many people, those who are addicted, and those who have a social problem like you. You can become a good lesson for those people, and a good example.

He also explained that he believed that he felt moved by this experience. He continued:

"The words that she used really touched my heart. I started thinking that she was a really good counselor". His response also underscores that religious organizations provide community members with support networks and connections to others through faith.

Community Gardening

Just nine community members explained that engaging in gardening provided them with a way to cope with stressors. These respondents were split almost evenly between the upper and lower castes. The lower castes (56 percent) consisted of four

Shudra respondents and one Vaisya. There were three Chhatriya and only one Brahmin participant, which comprised the higher castes (54 percent).

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One young woman from the Shudra caste (age 19) reported that gardening would be a helpful coping mechanism that would help a family member avoid problem drinking.

Our respondent asserts that gardening would help community members feel like they have something meaningful to do. She explained:

Yeah, he, I think he really does love gardening. Cause he um, we have a garden that, in the backyard. And he always like, you know, plant something, and just be busy. Yeah, I feel like if like, you know, they get something to do and they’re busy, I think they just like completely forget about like ok getting with friends and like drinking and all that. Because they have free time, they have nothing to do, so they just go and buy and drink.

This respondent also indicated that some members of the community might drink because they are bored. There is substantial evidence that newly resettled Nepali Bhutanese encounter several barriers associated with finding meaningful employment, navigating their communities, and integrating with their host societies (Dutton 2011; Gurung 2019;

Strang and Ager 2010).

During an interview with upper castes, one brahmin woman (age 25) indicated that community gardens would be an effective treatment for older adults. She explained:

Yea I think there are, especially if I talk about the oldest people, like over 50

years, they like to do the farm. Yeah, if they find someplace to do the farm, they

can even grow the food for them or sell for them; it would be busy there.

This community member's ideas are unique because she asserts community gardening also contributes to the neighborhood's economic development by allowing community members to sell their products. Community gardening helps Bhutanese Nepali seniors overcome stressors such as isolation and the inability to communicate with others (Gerber et al. 2017; Hartwig and Mason 2016). She continues to state that community gardening

149 would help older adults overcome feelings of isolation: "Even my dad he would sometimes try to come out and dig because he has that habit, but our people do not have anything to do".

PROVIDER RESULTS

Educational Programming:

An overwhelming majority of providers 18 of 20 (90 percent) indicated that expanding education programming would improve coping in the Bhutanese/Nepali community. Respondents worked for a wide variety of agencies including behavioral health centers (2 participants), resettlement agencies (3 respondents), community health centers (6 participants), and agencies providing a broad range of social services (7 respondents).

One provider working at resettlement explained that offering English classes would be an effective tool for reducing substance abuse problems. He argued that coming to an ELS class would foster a change in attitudes towards problem drinking. Our participant also suggested that classes help participants learn more about their host societies and the social norms associated with the United States:

Well? I think… uh… I think educating… Like we are IIA, we would have lots of classes over here. Okay, those with no English and those who speak quite a little English, Okay. And we're having uh um literacy classes uh, spoken classes, Okay, and we are trying our best to participate, more or more to discovery people and we are making a flyer, and we'll just give to community people so that they can come and enroll in the classes and whenever becoming in the classes definitely that will bring a change into their habits like attitude towards the alcoholism and all whenever they come to the class and hear new things about the US culture and all. So, we uh we are also trying our best.

His response suggests that community members who integrate with their host society will be less likely to engage in problem drinking. There is also substantial evidence that

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Nepali Bhutanese who speak English report experiencing fewer stressors associated with navigating their host societies (Benson et al. 2012; Dutton 2011). English courses could also be used as a safe space to discuss mental health, which is also highly stigmatized in the Nepali Bhutanese community (Dutton 2011; Miller et al. 2002).

Community Gardening

Just three of twenty providers described that community gardening would be a solution for problem drinking. Two respondents were working at a behavioral health clinic, which focused specifically on mental health treatment. The only other respondent worked at a community health center.

One respondent working at a behavioral health clinic described a successful client who engaged in community gardening to cope with difficulties finding work and avoiding problem drinking. His client had difficulties finding meaningful employment, and he took a minimum wage job in a warehouse. The provider reported that gardening was useful for helping his patient contend with sources of stress. He explained:

He was going to the garden and in a way that I see. He says I want to enjoy my

life. He's always been in the garden. It tells him to appreciate and, like gardening,

help him to feel that the future is there.

This respondent stresses that his client could escape from problem drinking through working in a community garden. He further asserts that gardening is deeply rooted in the

Bhutanese/Nepali identity. Our respondent explains, "Gardening is the tradition in Nepal like because our people are farmers".

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The respondent working at a community health center had some experience conducting research and conducted case studies on some of her Bhutanese/Nepali clients.

She explained:

You know, and then like one woman in my study she expressed like, she wished

that there was like more places for people to the garden because that's something

for the that the adults really have a hard time with is like after living outside and

being like farming people like to come here and be in a city and… They have like

this tiny backyard like having a place where they can farm and grow vegetables

and stuff and be helpful for some people […] It's just extremely therapeutic to be

outside and to be, you know, ecotherapy and ecopsychology is like a whole field.

So being outside is really helpful for stress.

This respondent underscores the therapeutic benefits of engaging in community gardening, and she also asserts that adults would benefit from engaging in working in the gardens.

DISCUSSION

This chapter aims to illuminate potential avenues for mental health and substance abuse offered by Bhutanese/Nepali community members and local social service providers. My project contributes to the literature on coping mechanisms by looking at how the caste system shapes Bhutanese/Nepali community members' experiences. Local providers stated that social services needed to be expanded to better meet the Nepali

Bhutanese population's unique mental health needs. Our providers suggested adding additional programs will solve stressors related to finding employment, accessing health services, and navigating the community. These results also support literature finding

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English as a second language course should be expanded and function as a safe space to discuss mental health concerns and problem drinking. Providers stated that the expansion of English courses would stop community members from engaging in problem drinking and overcome many of the barriers people encounter while integrating with their host societies.

Community members emphasized the importance of using their religious beliefs as a coping mechanism and being guided by a community leader. This theme was expressed by multiple community members who practiced several different types of religions. However, Nepali Bhutanese reported concerns about community leaders who are abusing drugs and alcohol. People born in the upper castes are forbidden from consuming alcohol and subscribe to being the community's spiritual leaders (Dhital et al.

2001; Subedi 2016a). This chapter also supports literature finding members of lower castes would convert to Christianity to escape sources of stress associated with the caste system (Patel 2012). Indeed, several of our lower caste respondents decided to convert to

Christianity. A few participants also indicated that starting to practice Christianity was life-changing, and reading the bible helped them distance themselves from stressors and problem drinking.

Several respondents also stated that engaging in community gardening could improve coping in the Bhutanese Nepali Community. Our participants suggested that older adults could participate in gardening, which would overcome feelings of isolation and depression. Senior citizens living in the Bhutanese community report feelings of alienation, difficulties learning English, and problems navigating their communities.

Respondents also indicated that simply being outdoors in a park would also be a useful

153 tool for improving coping and rekindling memories of being home in Bhutan. Providers also supported these feelings by discussing the therapeutic benefits associated with being in the garden and discussing clients who benefited from engaging in gardening.

Surprisingly, members of every caste reported that community gardening would be an effective tool for helping community members cope with stress. Further few studies have shed light on the relationship between the caste system and community gardening as a coping mechanism. This finding is consistent with other studies indicating that the

Bhutanese/Nepali community members would benefit from gardening because it is consistent with their identities as an agrarian culture (Hartwig and Mason 2016; Hinton

2016).

This chapter also indicates that future research could look at how coping varies based on participants who follow more than one religion. Woods and Pulla (2016) have found that Nepali Bhutanese may identify as belonging to multiple faiths. However, our team could only identify participants based on their most dominant religion, and our data did not seek to shed light on people who follow multiple religions. Another limitation of the chapter is that the data was not collected to address the caste system's influences on coping mechanisms, but the information included in the interviews is still capable of illuminating how coping can be improved. This study is also part of a larger project centered on substance abuse in the Bhutanese/Nepali community and was not intended to address the influences of the caste system. Finally, our cultural broker was well known in the Bhutanese/Nepali community and worked as a Christian pastor. His presence may have caused respondents to answer questions in a socially desirable way. Merits of the

154 study include a substantial sample of members of the Nepali Bhutanese community and a provider sample encompassing multiple social service agencies.

Conclusion

In conclusion, these results support literature that members of the Nepali

Bhutanese community have a different construction of mental health, and potential treatments should be culturally competent. Prior research indicates that members of the

Nepali Bhutanese community often report depressive symptoms as feelings of physical pain or an inability to communicate with others (Dutton 2011; Kohrt et al. 2009; Shannon et al. 2015). Indeed, local organizations could improve coping by offering culturally competent care to Bhutanese/Nepali community members. This project expands on prior literature by indicating that both providers and community members support expanding social services and English courses. Both providers and community members also indicated that community gardens help community members cope with stress, rebuild their connections to others, and relive their experiences in Bhutan. Community members described that religious beliefs could help them contend with stressors to a greater extent than providers. Findings suggest that each religious organization should have its own messages about problem drinking, and spiritual leaders can help community members deal with sources of stress.

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CHAPTER VI

CONCLUSION

This dissertation illuminates the caste system's influences on the

Bhutanese/Nepali community in Northeast Ohio. There is substantial evidence that

Bhutanese/Nepali refugees encounter acculturation stress upon resettlement into their host societies (Dutton 2011). Indeed, Bhutanese/Nepali often experience stressors related to finding employment, navigating their communities, rebuilding social networks, and gaining access to medical care (Dutton 2011; Shrestha 2011; Subedi et al. 2015). Prior scholarship has also found that community members often engage in problem drinking to cope with many of these stressors (Dutton 2011; Luitel et al. 2013). However, contemporary scholarship has seldom focused on how the caste system has shaped the experiences of Bhutanese/Nepali refugees and their health and wellbeing. To better understand caste inequalities, my dissertation employs in-depth interviews conducted with 100 members of the Bhutanese Nepali community and 20 individuals working for local social service agencies. The chapters of this dissertation were written as three independent studies that examine the caste system, and an additional chapter is included to provide background on events in Bhutan and Nepal.

The second chapter, "History and Culture," reviews the relevant literature on the ethnic cleansing in Bhutan and provides an overview of the resettlement process. During the 1990s, the Northern Bhutanese government feared losing the political power to the

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Southern Bhutanese and enacted policies marginalizing Bhutanese of Nepali descent

(Dutton 2011; Hutt 2005; Rizal 2004). Eventually, thousands of Bhutanese/Nepali were expelled from Bhutan, forced to travel through India, and create refugee camps in Nepal

(Hutt 2005). Refugees spent decades in the camps and seldom had opportunities to work or pursue higher education (Dutton 2011). Further political instability in Nepal often spilled over into camps, with refugees reporting bombings, human trafficking, killings, and sexual violence (Dutton 2011). In 2007, Bhutanese/Nepali refugees were resettled into western societies including the United States. There is some evidence that members belonging to higher castes were resettled before people belonging to the lower castes

(Dhungana 2010; Shanahan 2013). After refugees are resettled in the United States, they typically receive social services from local agencies. These agencies are often responsible for helping refugees accessing resources in the community, such as health services, housing, and employment (Dutton 2011; Shrestha 2011).

Chapter Three, "Caste as a Fundamental Cause," presents the narratives of three community members who were resettled in Northeast Ohio. Two overarching research questions guided the analysis of these stories. The first question is, "How do sources of stress and inequalities tied to the Bhutanese caste system shape the resettlement experiences of refugees to the United States"? Next, "What are the consequences of this caste system for refugees' health and well-being"? Tika and Prakesh underscore the complexities of intercaste marriage. When their daughter became ill, Prakesh embraced the traditional cures associated with the Shudra caste, but Tika, a brahmin, advocated for formal medical care. Sarah's story demonstrates that younger generations are less likely than their parents to subscribe to the caste system. However, the caste system continues

157 to shape the lives and health of adults. Caste status negatively impacted Sarah's father's health. Bhim's narrative teaches us that the upper castes have access to more economic and social resources. However, older adults and people with disabilities may not be protected by their higher caste status. In general, these narratives demonstrate that caste influences health upon resettlement.

Chapter Four, "The Caste System: Barriers to Integration and Healthcare," examined the influences of the caste system and acculturation stressors as barriers to integration and access to care. Prior chapters established that Bhutanese/Nepali refugees encounter several stressors upon resettlement (Shanahan 2013; Shannon et al. 2015), but they also often function as barriers to integration and medical treatment (Ager and Strang

2008). Two research questions also guided this chapter. Foremost, "How does caste status prevent refugees from accessing social services and mental health treatment". Next,

"What are the other barriers resettled refugees encounter when attempting to access social services and treatment? Findings demonstrate that members of the lower castes (Shudra and Vaisya) experience more barriers to work and language than members of the higher castes. Regardless of caste, respondents indicated that stigma is a barrier to integration, and many respondents also experienced difficulty reestablishing social networks.

Chapter five is entitled "Culturally Competent Mental Health Treatment". In this chapter, the stress process model is employed to shed light on improving the coping mechanisms within the Bhutanese/Nepali Community. There is substantial evidence that effective coping mechanisms include mastering English, practicing religion, and engaging in community gardening (Dutton 2011; Halsouet 2013; Hinton 2016). This chapter is guided by the research question: "How can providers and community members

158 improve the mental health and coping mechanisms of Bhutanese Refugees". Findings reveal that lower castes reported that converting to Christianity helped distance themselves from negative stereotypes associated with their castes. Some individuals belonging to the upper castes practiced Christianity, but many still followed Hindu traditions. Individuals belonging to every caste asserted that social services need to be expanded better to meet the Bhutanese/Nepali community's needs. Respondents stressed that social services should help them find employment, gain access to citizenship, and learn English. Regardless of caste, participants suggested that community gardening would be an effective strategy for improving coping in the Bhutanese/Nepali community.

Theoretical Contributions

This project contributes to the literature on acculturation stress, which posits members of forcibly displaced populations may cling to traditions (Scudder and Colson

1982). My findings demonstrate that some community members may continue to embrace the caste system upon resettlement. Clinging to the caste system is reflected through Chapter three when Prakesh tried to treat his daughter's physical and mental illness through traditional remedies. For example, he took his daughter to see a shaman and gave her aromatic plants believed to have medicinal properties. In another narrative,

Sarah's father began consuming alcohol at family events, which is normative for lower castes. However, he eventually began to consume excessive amounts of alcohol to cope with many of the stressors he encountered finding employment and medical care. There is also some evidence that members of the upper castes still subscribe to their identity as teachers of spirituality and should not consume alcohol (Dhital et al. 2001). In the last chapter, some providers assert that higher castes may be rushed into treatment if they are

159 found consuming alcohol, which further supports the acculturation stress literature and the caste system's persistence.

My dissertation also furthers the literature on fundamental causes. I argue that the caste system continues to shape health outcomes and operates as a fundamental cause of illness. According to Link and Phelan (1995), fundamental causes have (a) multiple disease outcomes, (b) multiple risk factors, (c) disparate resources, and (d) are time irrelevant. Prior research has found that members of lower castes often work and live in harsh conditions. For instance, the narratives presented in chapter three illustrate that lower castes suffered injuries related to their work.

On the one hand, Sarah's father fought in the military and suffered from eye and hand injuries. Her father could only work in low-wage occupations, which did not provide fringe benefits. On the other hand, Bhim was a Brahmin caste member and could successfully find a full-time job upon resettlement. Bhim's story also suggests that the caste system may function as a countervailing mechanism, and caste status may not offer protections to aging adults or persons who have a disability.

This project further illuminates how the caste relates to cultural health capital

(CHC). According to Shim (2010), CHC posits that individuals who have access to more social and economic resources have an easier time navigating healthcare systems.

Gengler (2014) has found that higher-status individuals often push for medical care and advocate for their treatment. In chapter three, these findings are mirrored through Bhim, a brahmin, who could gain medical coverage through his work. He could also use his expertise to help his aging mother and sister with a disability find medical coverage. Tika is another member of the highest caste and leveraged her friendships to get her daughter

160 medical treatment from a hospital while still living in a refugee camp. On the other hand,

Sarah's parents struggled to access medical care and often had to work overtime to make ends meet. Sarah stresses that she often needed to interpret English for her parents, who struggled to make appointments or speak to a medical professional.

This project also contributes to scholarship on integration theory. I use a modified version of Ager and Strang's (2008) theory to examine the barriers refugees encounter integrating with their host society and gaining access to medical care. My theoretical model posits that migrants who integrate with their host society experience fewer difficulties accessing medical care. I anticipate that people who belong to the lower castes will experience more barriers than the upper castes. Regardless of caste, respondents indicated that stigma is one of the largest obstacles experienced by community members.

Indeed, mental health is often taboo (Shannon et al. 2015) and is not discussed within the community. Members of both castes also said that they could not re-establish social networks upon resettlement, which slowed their access to integration and healthcare. My findings also support the literature that Bhutanese/Nepali refugees were split from their extended families during the resettlement process (Dutton 2011; Lundström and den Uyl

2010). Members of higher castes indicated that they might have completed a secondary migration closer to members of their extended family. People belonging to the lower castes asserted that they struggled to reconnect with family post resettlement.

Results also suggest that members of the lower caste experienced more barriers to integration related to finding employment. For example, Shudra respondents indicated there are no jobs in Northeast Ohio or that employers would not recognize their credentials from Bhutan or Nepal. There is substantial evidence that members of the

161 lower castes often work in the service sector and precarious occupations (Furr 2005;

Gellner 2007; Subedi 2016b). On the other hand, members of higher castes have access to more social and economic capital (Subedi 2016b), which may have benefitted Brahmin and Chattriya when transitioning to a western economy. Lower caste respondents also stressed that they experienced more language and culture barriers than the upper castes.

Members of the lower castes were also more likely to suggest that they were dependent on their children for making medical appointments. Indeed, this is reflected through

Sarah's story because she was responsible for helping her parents find doctors and reach out to medical professionals.

Finally, this dissertation sheds light on how coping mechanisms can be improved in the Bhutanese/Nepali community. I employ the stress process model to acknowledge the traumatic life events experienced by community members. Several studies have found that Bhutanese/Nepali conceptualize mental health differently than the western medical model. Therefore, coping mechanisms should be culturally competent to meet the

Bhutanese community's mental health needs adequately. This project has found that members of every caste believed that social services needed to be expanded. For example, local agencies should offer vocational training, interpretation services, and

English and citizenship courses. People from every caste also believed that community gardening would also be an effective coping mechanism. Engaging in gardening helps community members reconnect to their society of origin (Hartwig and Mason 2016;

Hinton 2016).

In conclusion, this dissertation expands on several different theoretical frameworks, which have seldom applied the caste system to illuminate refugees'

162 experiences. The acculturation stress literature illustrates that some refugees may cling to traditions associated with their host society. Indeed, many community members continued to follow the caste system upon resettlement in Northeast Ohio. Next, there is substantial evidence the social inequalities function as a fundamental cause of health and illness. This study contributes to the health disparities literature by finding that the caste system shapes health outcomes upon resettlement. I also find that the higher castes often have access to more capital than lower castes. This project also contributes to the literature on integration theory by shedding light on the difficulties members of lower castes have finding work and mastering English. This project's last contribution is to the literature on coping by finding that offering more social services would benefit every caste. This project supports literature finding that lower castes may have converted to

Christianity to cope with stressors. However, members of the upper castes often still carry out Hindu rituals as a coping mechanism.

Limitations of the Current Study

Although this project contributes to the literature, there are still several limitations to the data. The largest limitation of this project is questions from the larger research project were not focused on participant caste. When reviewing the informed consent form, our cultural broker recorded the respondent's caste along with other demographic variables. Caste status remains a sensitive topic in the Bhutanese/Nepali community, and some respondents may have been reluctant to answer questions related to their social position. I argue that the data can still illuminate how the case system persists upon resettlement to Northeast Ohio. This project's data came from a more extensive study called the Bhutanese Refugee Substance Abuse Study (BRSAP). The original project was

163 intended to measure community members and provider perceptions of substance abuse in the Bhutanese/Nepali community.

The interviews covered three sections including (a) the participants' background

(e.g., How long have you lived in Akron), (b) use of social services (e.g., Have you received any services from other providers in the community?), (c) perceptions of alcohol use (e.g., Why do you think people are drinking?), and (d) solution to alcohol abuse (e.g.,

What do you think the community needs to treat alcoholism?). Our dataset also included several demographic variables (e.g., age, caste, and religion), which are representative of the Bhutanese/Nepali community. This information would have been difficult for researchers to collect using another method. Indeed, there is stigma attached to caste, mental health, and substance abuse in the Bhutanese/Nepali community. Therefore, this dataset is ideal for understanding the relationship between caste and mental health.

As noted in the last section, our interpreter also worked as a Christian pastor, and his presence may have influenced our respondents' responses. Many of the interviews were also conducted in Nepali, which may not accurately reflect the participants' views.

However, I trust the validity of these interviews, which allowed us to analyze the community's perceptions of problem drinking thematically. Another limitation of the project is that our demographic variables were not treated as being mutually exclusive.

Some studies have found that the Bhutanese community members may practice multiple religions upon being resettled in the camps (Halsouet 2013). However, one religion was typically more dominant, and while conducting interviews, I noticed participants often had relics associated with one religion. For example, dominantly Christian families hung crosses on the walls, but Hindu families typically had shrines or paintings devoted to the

164 gods. Regrading respondent caste, I am confident that we obtained the best measure possible with our cultural broker's help. Caste is an ascribed status grounded deeply in race and ethnicity (Gellner 2007), and community members are typically unable to move out of their social positions.

Another limitation of this project is that many of the interviews were conducted with multiple participants. Our team often intended to interview one participant, but other family members were often present during the interviews. When this occurred, we had

Santa ensure all participants completed a consent form and obtained their demographic information. Multiple could have been a concern due to the patriarchal nature of the

Bhutanese/Nepali community. At times, we noticed that husbands would dominate conversations, but we would often ask their partners about their perceptions of alcohol, mental health, and solutions. We also sometimes interviewed parents and their children.

During most of these interviews, the adult was often more dominant than their child. To mitigate these concerns, I applied a demographic case to each speaker, which allowed me to discern who was speaking in an interview with multiple respondents. Using demographic cases ensured that each respondent was accounted for when conducting crosstabs in NVivo.

Merits of this project include a large sample of community members and providers. We conducted interviews with 100 community members. As previously noted, our sample provided a representative snapshot of the Bhutanese/Nepali community's diversity. Our sampling approach ensured we included people regardless of gender, age, caste, and religion. Additionally, this dissertation employs interviews conducted with 20 social providers including two focus groups with large agencies in Northeastern Ohio.

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We sampled a diverse group of providers including resettlement agencies, mental health clinics, community health centers, and law enforcement officers. By including provider interviews, my dissertation can offer a deeper look into the local agencies that deliver care to members of the Bhutanese/Nepali community and the social structures they are rooted in.

Another advantage of this dissertation is using multiple analytical strategies to shed light on my research questions. The purpose of this dissertation is not to be generalizable to other populations but rather further our understanding of sociological theory and the caste system. On the one hand, I achieve this by using crosstabs, which illuminates community-related experiences to health disparities and potential solutions.

This method is appropriate because it allows us to thematically analyze the barriers to treatment for each caste and potential solutions. I argue that this is relevant because it illustrates how social inequalities continue to shape health outcomes in the

Bhutanese/Nepali community. On the other hand, I use a narrative approach in chapter three to offer insight into my participants' lives.

Role of the Researcher and Team

This dissertation is part of a larger project called the Bhutanese Refuge Substance

Abuse Study (BRSAP). This project was suggested by Radha Adhikari, who worked as the Director of Social Services at the International Institute of Akron. In 2015, social services began to experience increases in alcohol abuse cases in the Bhutanese/Nepali community. Indeed, there is substantial evidence that Bhutanese/Nepali community members are more likely to have a disorder related to alcohol use than other forcibly displaced populations (Luitel et al. 2013; Shannon et al. 2015). Radha worked to

166 understand the problems related to alcohol abuse, but she was not a social scientist.

Further, she was new to Northeast Ohio and did not have any rapport with the community. Radha is also a Brahmin caste member, which may have prevented

Bhutanese/Nepali community members from disclosing their experiences with alcohol use. These factors compelled Radha to contact the University of Akron to understand problem drinking and develop culturally competent programming for Bhutanese/Nepali community members.

Dr. Marnie Watson led our research team, served as the primary investigator, and collaborated with the International Institute. She works as an Assistant Professor of

Anthropology at Missouri State University and is a Research Associate at the University of Akron. Our team consisted of three graduate students including Nuha Alshabani

(Counseling Psychology), Jimmy Carter, and myself (Sociology). We were joined in the field by Julian Curet, who is an undergraduate student majoring in anthropology. Each of these members was responsible for conducting interviews with participants, transcription, and coding. Additionally, Vyshu Ramini (Pre-Medicine/Biology) assisted us with the transcription and coding of interviews. We presented as researchers from the University of Akron who were collaborating with the International Institute of Akron.

As a researcher, my role was to further the sociological literature through the development of this dissertation. Further, I held a paid internship with the International

Institute of Akron who planned on using the data to inform the development of a culturally competent alcohol treatment program. During data collection, I was in my early twenties and presented myself to community members as a white male graduate student.

My fellow research assistants identify as white, one as Arab American, and another as

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Biracial (Southeast Asian and Caucasian). Although we had a background in conducting research, our team was still outsiders in the Bhutanese/Nepali community. Through our collaboration with the international institute, we needed a cultural broker to ensure that we respected the Bhutanese/Nepali community's traditions. Further, we intend to inform our community partner of academic projects to ensure that our research accurately represents the community. Indeed, researchers should strive to work with their community partners to provide a trustworthy relationship is maintained and participants are respected in scholarly works (Ellis, Adams, and Bochner 2011).

The International Institute hired Santa Gajmere to work as our team's interpreter and cultural broker. He was responsible for interpreting interviews when conducted in

Nepali and ensured that participants were briefed when completing the informed consent form. Santa worked as a Christian pastor and was well known in the Bhutanese/Nepali community. We only spent four months conducting interviews, and Santa used snowball sampling to connect us to participants rapidly. One issue is our snowball sampling strategy may have led to sampling bias. For instance, respondents may have been Santa's friends, neighbors, or church members. However, we used target sampling to ensure our respondents represented the Bhutanese/Nepali community's diversity. Target sampling confirmed that our respondents came from a variety of different castes and religions. His presence may have caused respondents to respond to interviews in a socially desirable way. Our primary investigator, Dr. Watson, encouraged Santa to focus on his role as our interpreter rather than to pass judgment on respondents as we continued to conduct interviews. I conclude this section with a personal narrative regarding the cuts being made to the International Institute.

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Personal Reflections: Refugee Resettlement in Crisis

During our time conducting research, the International Institute of Akron began to suffer from budget cuts and was forced to lay off dozens of caseworkers. According to

Santa, the International Institute received more than $600,000 in federal funding.

However, during the summer of 2016, the federal government slashed their annual funding to only $200,000. Government funding needed to be partitioned among each of the institute's programs and staff members. Shortly after these cuts were made, the institute was forced to lay off nine employees, which was just over 33 percent of their staff. We had 27 of 100 community members report that many of the social services they received were inadequate due to funding issues. There were another 19 respondents who thought employee morale seemed low due to budget cuts. One Brahmin man mentioned,

"Everyone working there is frustrated… They had their budget reduced. Some of them are scared they will lose their jobs".

In Spring 2017, one year later, I returned to the International Institute to observe a citizenship course for my qualitative methods course. Last summer, their education department was a bustling hub of activity, and at least a dozen students regularly attended classes. During my observation, there was only one community member present for the entire class session. With fifteen minutes left in the lecture, a second student meandered into class. The community member mentioned he had problems getting a ride. After class, I had a brief conversation with the instructor, who mentioned that only volunteers were teaching courses. Most of the education department staff had gradually been laid off due to the increasingly tight budget. The remaining former instructors were reassigned as caseworkers.

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During summer 2019, I tutored reading at local elementary schools and worked as a volunteer coordinator. I enjoyed this job because it helped me rekindle my connection to the community and offered me the opportunity to hone my teaching skills. On my drives to work, I watched as construction crews gradually gutted the International

Institute's interiors carrying out bits of furniture and construction materials. One morning,

I remember seeing a bright yellow bulldozer in the institute's tiny parking lot. Driving home, I stopped at a red light watching the excavator's bucket tear through the institute's familiar red bricks. In seconds, the exterior was reduced to rubble as the bulldozer continued to shred the former resettlement agency to pieces. Then the light turned green, and I continued on my drive home. I had a meeting in an hour, and I did not want to be late. When I tapped my car's accelerator, only half of the International Institute was still standing.

The building that housed the international institute22 was initially built in 1960 and offered services to women born outside of the United States (Anon 2019). After the second world war, they expanded their services to families displaced by World War II

(Anon 2019). In late 1970, the International Institute became recognized as a resettlement agency, and they continue to provide services for migrants and forcibly displaced populations (Anon 2019). The former women's center had stood at the heart of Akron's immigrant community for over a century. While tutoring reading, I had forgotten that the building had been condemned for being unsafe. Occasionally, someone would complain about some minor problem with the structure. When I witnessed the demolition, the event

22 As noted on the International Institute's webpage (Anon 2019), their name has changed several times. In 1916 they were called the "Young Women's Christian Association" (YWCA). Around 1930, with local funding they changed to "The International Center". Finally, they were renamed "The International Institute of Akron" (IIA) in 1958 (Anon 2019).

170 was deeply shocking to me. I always remembered that building being full of life and energy. It was the place I was exposed to qualitative methods and worked as an applied sociologist for the first time. Now the agency is currently housed on a local hospital campus and continues to provide the immigrant community with many of the same services.

Contemporary Refugee Resettlement Policies

In 2016 the Trump administration enacted policies dropping the refugee ceiling from 110,000 to just 50,000 (La Courte 2019; McHugh 2018). For three months, all refugee admissions into the united states were suspended, and more stringent vetting procedures23 were enacted (Pierce 2018). In 2018, the ceiling for refugee admissions was further plunged to 45,000, and by 2019, admissions sank to 30,000 (McHugh 2018). In

2020, the ceiling was dropped to 18,000, but only 11,000 refugees were admitted to the

United States. (Ries 2020; Rush 2020). With these sharp declines in admissions, many resettlement agencies like the International Institute have been forced to lay off employees and slash budgets (La Courte 2019; Pierce 2018). Agencies have been forced to make substantial cuts to programming related to finding employment, accessing medical care, and learning English (La Courte 2019; McHugh 2018). Ager and Strang

(2008) remind us that social services are vital for helping refugees integrate with their host society. When resettled refugees integrate, they have higher rates of education and employment than members of their host society (La Courte 2019; McHugh 2018; Pierce

23 Prior to the Trump administration the process for vetting refugees was already lengthy and refugees need to complete several interviews (Scribner 2017).

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2018). Integrated refugees also pay billions in taxes, which surpasses the amount tendered in benefits (Pierce 2018).

These dramatic policy changes have exacerbated global refugee crises and destabilized international refugee resettlement. There is substantial evidence that the

United States has been a world leader in resettling refugees after global catastrophes and has worked to resettle individuals caught in humanitarian crises (La Courte 2019;

McHugh 2018; Pierce 2018). Further, the United States has contributed more financial support to global resettlement organizations and typically admits more refugees than any other country (Norman 2019; Scribner 2017). Since the 1980s, the United States adopted a standardized approach to admitting refugees, which connects refugees to the services they need to become self-sufficient (Norman 2019; Scribner 2017). Further, the refugee act worked to frame refugee resettlement as a humanitarian issue and worked to reduce stigma towards refugees from nonwestern countries. In 2020, Canada will become the world leader in refugee admissions24 surpassing the United States and the world.

The Biden administration has worked to raise the maximum number of refugees from 18,000 to 125,000 (Ries 2020), which is roughly seven times larger than the previous cap (Ries 2020; Rush 2020). On the one hand, the Biden administration will work to ensure that families are resettled together. Bhutanese/Nepali refugees report that being separated from family members is a significant source of stress (Dutton 2011;

Lundström and den Uyl 2010). On the other hand, the Trump administration centered the admission of refugees and immigrants on education and skills (Ries 2020). However, these policies would further marginalize Bhutanese refugees who have accreditations not

24 The current ceiling for refugee admissions in Canada is 30,000 and the United States will only admit 18,000 refugees (Norman 2019).

172 recognized by the United States (Dutton 2011). Although the Biden administration has enacted policies that would benefit refugees, there are still several challenges. Ramji

Nogales (2021) argues that the new administration should strive to reframe immigration as beneficial and eschew the populist agenda that portrays immigrants as a security threat.

Policy Recommendations

At the local level, community members encounter many barriers associated with integration into their host society. Narratives suggest that resettled community members experience difficulties rebuilding social networks, learning English, finding employment, and accessing healthcare. Another key finding is that interventions should be culturally competent and respect the diversity of the Bhutanese community. Respondents suggested that a community leader would guide effective interventions, and each religion should strive to develop its own message regarding mental health. However, attempting to strengthen programs at the local level needs adequate support from the federal government. I offer the following recommendations:

1. Local agencies should strive to be sensitive to community member

caste. This dissertation demonstrates that the caste system continues to function as

a cause of mental health. Lower caste members typically reported encountering

more barriers to integration than people in the upper castes. Scudder and Colson

(1982) suggest that some refugees may cling to the caste system to cope with the

new stressors of their host society.

2. The Bhutanese/Nepali community is very diverse, and mental health

messages should come from each community leader. Respondents indicated that

some community members might be reluctant to follow leaders who practice

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another religion. The best intervention would come from someone who followed

the same religion.

3. Effective programming allows refugees to rebuild their social networks.

Participants reported that they would benefit from engaging in community

gardening or practicing their religion with others. These programs would also

allow community members to build connections with others outside of their

communities. There is substantial evidence that social support providers are a

buffer against mental health conditions (Pearlin 1989; Thoits 1995).

4. Social services should be adequately funded by the national government

and can continue offering programming vital to refugees' integration. Cuts made

to funding and the federal admissions ceiling have damaged local organizations'

ability to deliver culturally competent programs. Refugees need programs that

help them find employment, access medical care, and learning English (Ager and

Strang 2008). These programs help refugees integrate with their host society and

ensure refugees strengthen local economies.

5. National immigration policies should strive to ensure that families are

resettled together, which would remove a source of stress many Bhutanese/Nepali

refugees encounter upon resettlement. Refugee admissions should not be made

based on individual credentials, which are often not recognized.

These policy recommendations stress that the struggles of local resettlement agencies are rooted deeper in government policies. Although the Biden administration has increased the refugee admission ceiling, local agencies need to be adequately funded and staffed to ensure newly resettled refugees are capable of integrating with their host society.

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Conclusion

In sum, this dissertation demonstrates that the caste system continues to influence health stratification upon resettlement. The caste system likely functions as a fundamental cause of illness through the multiple pathways that foster adverse mental health outcomes for the lower castes. Indeed, lower caste members often work in hazardous occupations and are at increased risk for injury and illness. Further, the lower castes encounter additional stressors through encounters with open discrimination from the higher castes.

Members of the higher castes often have access to more cultural health capital (CHC), making treatment easier to access. In contrast, the lower castes were often marginalized by policies restricting their ability to access care and navigate their host societies.

This dissertation also illuminates the challenges Bhutanese/Nepali community members encounter upon resettlement into their host societies. There is substantial evidence that refugees encountered stressful life events during their flight from Bhutan and time in the camps. These events often become persisting life strains, which become exacerbated during the integration process. Resettled refugees experience many barriers to integration and healthcare connected to finding employment, learning English, and connecting with others. To ensure that resettled refugees can integrate into our society, the federal government needs to raise the ceiling on admitted refugees. Without culturally competent programming, the acculturation stressors refugees face will likely become persisting life strains. Findings suggest that programs should focus on helping resettled refugees learn English, practice religion, engage in community gardening, and rebuild social networks.

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APPENDICIES…………………………………………………………………………193

APPENDIX A. COMMUNITY MEMBER INFORMED CONSENT FORM…………………………………………………………………………………..194

APPENDIX B. COMMUNITY MEMBER INTERVIEW GUIDE………………………………………………………………………………….197

APPENDIX C. PROFESSIONALS/PROVIDERS INFORMED CONSENT……………………………………………………………………………...200

APPENDIX D. PROFESSIONAL/PROVIDER INTERVIEW GUIDE………………………………………………………………………………….203

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APPENDIX A

COMMUNITY MEMBER INFORMED CONSENT FORM

Department of Anthropology and Classical Studies Buchtel College of Arts and Sciences Akron, OH. 44325-1910 (330) 972-7875 Office (330) 972-2338 Fax

Bhutanese Refugee Substance Abuse Study Interview Informed Consent Script (Community Members) You are being invited to take part in a research study investigating alcohol and drug use in the Bhutanese community in Akron, Ohio. This study is a collaborative effort between researchers from the University of Akron and the International Institute of Akron. We would like to talk to you for approximately 30 minutes to hear your thoughts about alcohol abuse in the Bhutanese refugee community.

The purpose of this study is to design a better program to help community members get treatment for alcohol and drug use. The information you share will help us understand the problems that alcohol use is causing in the community and will shape the new program we are working hard to create. For example, we will ask you about your experience with services at the International Institute, and if you have suggestions to improve services. We will also ask if you have seen alcohol cause problems in your community, and what those problems were.

Participation in this study is completely voluntary. You do not have to participate if you do not want to. If you do not wish to participate, please feel free to say, “no, thank you,” and we will not ask you any further questions. If you agree to participate, but do not want to answer a particular question, you do not have to do so. If you wish to stop the interview at any time, please tell me, and we will stop immediately. If after the interview is finished, you wish to remove yourself from the study, please tell me, and you will immediately be removed. Nothing bad will happen to you if you chose not to participate or not to answer any question, and you may remain in the study even if you choose not to answer certain questions. Deciding not to participate in the study will not in any way affect any services that you are receiving from the International Institute or any other service provider. If after we talk, you want me to erase any recordings we make, I will immediately do so. Again, this is no problem and nothing bad will happen to you if you ask me to erase any recordings of this interview.

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This interview will be recorded using a digital recorder. Afterwards, the interview recording will be typed up and the audio recording destroyed. Since this research study is intended to help treat alcohol use among Bhutanese refugees, we intend to share our findings with other communities around the country that are struggling with the same problems. The treatment program that results from this research will also be shared with other communities and treatment providers. It is also possible that information from this interview will be used to write academic articles with the intent of sharing potentially helpful information about this subject with other researchers, communities, and treatment providers. While we will ask for your gender and your age, we will not record your name or any other personal information about you, your family, or anyone you might mention while talking to us. An audio recording of this interview and any transcripts will be stored on a password- protected computer at the University of Akron. The research team will do everything possible to keep these materials safe.

Possible risks of participation: It is possible that during an interview you may discuss topics that may be personal. If you wish at any time for this information to be destroyed, the researcher will do so.

Benefits of participation: You will receive a $10 gift card for participating in this study. In addition to this, information from this research will help us to design a better program to treat alcohol and drug abuse in the Bhutanese refugee community.

You can choose whether to participate in this study or not. If you volunteer to participate, you may withdraw at any time without penalty of any kind. You may also refuse to answer any questions you do not want to answer and still remain in the study.

Do you have any questions about this research study? Please take as much time as you need to decide if you would like to participate or not. Nothing bad will happen to you if you choose not to participate.

Do you choose to participate? Yes, I choose to participate. ______(Translator marks an X and date) date

Gender: ______

Age: ______

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If you have any questions or concerns about the research, please feel free to contact: Dr. Marnie K. Watson, phone number 330-283-5544, Dr. Carolyn Behrman 330-671-5397, Radha Adhikari 858-226-7563, or Santa Gazmere 757-725-0480.

If you have other concerns or complaints, please contact the Institutional Review Board at the University of Akron, 330-972-7666, or: The University of Akron Office of Research Administration Akron, OH 44325-2102

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APPENDIX B

COMMUNITY MEMBER INTERVIEW GUIDE

Bhutanese Refugee Substance Abuse Study

Semi-Structured Interview Guide (Community Members)

Interviewer(s): ______Date: ______

Part I: Participant Background

1. How long have you lived in Akron? (Probes: When did you come to the US? Have you lived in other places in the US? If so, where?)

2. What are some positives about Akron?

3. What are some negatives about Akron? (Probe: If you have lived in other places in the US, what was better/worse in those communities?)

Part II: Use of Services: Includes medical services (physical or mental health), counseling, employment assistance, legal assistance, or any other services used.

4. Have you received any services from the International Institute of Akron? (Probes: if so, what kind of services? What did you think of those services?)

5. What are some positives about the International Institute of Akron?

6. What are some negatives about the International Institute of Akron?

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7. Have you received any services from other providers in the community? (Probe: If so, where? What did you think of those services?)

Part III: Perceptions of Alcohol Use in Community

8. Do you think alcohol use is a problem in the Bhutanese community in Akron?

9. Who is drinking alcohol in the Bhutanese community? (Probe: Men/women? Minors? Age range?)

10. What kind of alcohol are people drinking? (Beer? Wine? Hard liquor? Homemade liquor?)

11. Where do people drink alcohol? (Probe: At home, bar, restaurant, etc.?)

12. When are people drinking alcohol? (Probe: All day? Evenings only? Weekends only?)

13. Why do you think people are drinking? (Probe: For fun? Friendship? Relaxation? To feel better or relieve stress? Holidays, ceremonies, or celebrations?)

14. Have you seen alcohol cause problems in the community? If so, what problems? (Probe: Have you seen other substances being abused in the community? If yes, what problems have they caused?)

Part IV: Treatment of Alcohol

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15. Do people in the community with alcohol problems seek help? (Probes: If yes, where do they seek help: from family, friends, doctors, religious specialists, community leaders, AA? If from a specific treatment provider, which provider/agency?)

16. Why is it difficult sometimes for people in the community to seek help for alcohol problems?

17. What do people think about alcoholics or people who drink too much? (Probe: What do you think?)

18. What do you think the community needs to treat alcoholism and alcohol-related problems?

19. Do you have any other comments or ideas that you would like to share?

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APPENDIX C

PROFESSIONALS/PROVIDERS INFORMED CONSENT FORM

Department of Anthropology and Classical Studies Buchtel College of Arts and Sciences Akron, OH. 44325-191 (330) 972-7875 Office (330) 972-2338 Fax

Bhutanese Refugee Substance Abuse Study Interview Informed Consent (Professionals and Providers) You are being invited to take part in an interview as part of a research study investigating alcohol and drug use in the Bhutanese community in Akron, Ohio. This study is a collaborative effort between researchers from the University of Akron and the International Institute of Akron.

The purpose of this study is to design a better program to help community members get treatment for alcohol and drug use. The information you share will help us understand the problems that alcohol use is causing in the community and will shape the new program we are working hard to create. For example, we will ask you about your experience with providing services for people in the Bhutanese refugee community in Ohio, and if you have suggestions to improve services. We will also ask if you have seen alcohol cause problems in the Bhutanese refugee community, and what those problems were.

Participation in this study is completely voluntary. You do not have to participate if you do not want to. If you agree to participate, but do not want to answer a particular question, you do not have to do so. If you wish to stop the interview at any time, please tell me, and we will stop immediately. If after the interview is finished, you wish to remove yourself from the study, inform anyone from the research team, and you will immediately be removed. There will be no negative repercussions if you chose not to participate or not to answer any question, and you may remain in the study even if you choose not to answer certain questions. If after we talk, you wish me to erase any recordings we made, tell anyone on the research team, and all recordings will immediately be erased.

This interview will be recorded using a digital recorder. Afterwards, the interview recording will be typed up and the audio recording deleted. Since this research study is intended to help treat alcohol use among Bhutanese refugees, we intend to share our findings with other communities around the country that are struggling with the same problems. The treatment program that results from this research will also be shared with

200 other communities and treatment providers. It is also possible that information from this interview will be used to write academic articles with the intent of sharing potentially helpful information about this subject with other researchers, communities, and treatment providers.

An audio recording of this interview and any transcripts will be stored on a password- protected computer at the University of Akron. The research team will do everything possible to keep these materials safe.

If you choose, you may remain anonymous. In that case, while your personal information will not be linked in any way with to the interview recording, we do ask that you sign this consent form. The consent form will be stored separately from interview recordings, in a locked office.

Possible risks of participation:

It is possible that during an interview you may discuss topics that may be personal or opinions that differ from other providers and professionals in the community. However, we will do everything possible to protect your anonymity, if you wish to remain anonymous. If you wish at any time for this information to be destroyed, the research team will do so.

Benefits of participation:

You will not receive any monetary or material benefits from participating in this research study. However, information from this research will help us to design a better program to treat alcohol and drug abuse in the Bhutanese refugee community.

Please feel free to ask any questions you have before choosing whether you will participate.

I choose to participate. ______Name Date

I wish to remain anonymous. Yes ______No ______

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202

APPENDIX D

PROFESSIONAL/PROVIDER INTERVIEW GUIDE

Bhutanese Refugee Substance Abuse Study

Semi-Structured Interview Guide (Professionals/Providers)

Interviewer(s): ______Date: ______

Part I: Participant’s Work

1. Please describe the work you do with the refugee community in Akron in general.

2. Besides your own work, what resources does Akron offer to help refugees?

3. In your experience, what problems do refugees face when coming to Akron?

4. Does the Bhutanese refugee community face any different or additional issues, compared to other refugee groups you have worked with?

Part II: Participant’s Perceptions of Substance Abuse in the Bhutanese community

5. Do you think there is a problem with alcohol or other substance abuse in the Bhutanese refugee community? (Probes: If yes, why? What specific problems have you seen or heard about?)

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6. Who is drinking alcohol in the Bhutanese community? (Probe: Men/women? Minors? Age range?)

7. What kind of alcohol are people drinking? (Beer? Wine? Hard liquor? Homemade liquor?)

8. Where do people drink alcohol? (Probe: At home, bar, restaurant, etc.?)

9. When are people drinking alcohol? (Probe: All day? Evenings only? Weekends only?)

10. Why do you think people are drinking? (Probe: For fun? Friendship? Relaxation? To feel better or relieve stress? Holidays, ceremonies, or celebrations?)

Part III: Participant’s Perceptions of Substance Abuse in the Bhutanese community

11. What success have you seen in providing treatment for alcohol or drug abuse for people from the Bhutanese refugee community?

12. What challenges have you seen in providing treatment for alcohol or drug abuse for people from the Bhutanese refugee community?

13. What do you think the Bhutanese refugee community needs to effectively address alcohol abuse and the problems that it causes?

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14. Do you have any other comments or ideas that you would like to share?

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