Preface

A Call for Better Tertiary Responses to Torture

The Need to Train Health Professionals

Despite the growing number of survivors of torture, refugees, and people with related traumas (1-4), US health professionals learn little during their training about caring for this patient population. Two surveys suggest that only a minority of medical and public health schools teach about domestic and international human rights violations and the medical, mental health, social, and legal consequences of such violations (5-6). In addition, health professionals who work primarily in large urban centers have corroborated that they are ill-prepared for the task of caring for this patient population (7), which according to two different surveys compromises between 5 and 10% of all foreign patients seen in these medical centers (8-9).

In our own experience at the Boston Center for Refugee Health and Human Rights, we found that 85% of refugees and asylum seekers who had a primary care physician and 60% of this patient population who had contact with some other health professional were never asked about human rights abuses.  We also found that the mean time between arrival to the US and the first contact with a health professional aware of resources available for this patient population is 4.4 years, with a range of 2 months to 15 years. This lack of recognition of the needs of refugees and survivors of torture explains, in part, why a successful reintegration into society takes so long for most of these patients.

During the celebration of the 50th Anniversary of the Universal Declaration of Human Rights, the Consortium for Health and Human Rights called all health professionals-including medical, public health, and nursing schools-to increase global awareness of the relationship between health and human rights (10). The Consortium recognized that health professionals are in a unique position to advance the well-being of torture survivors, refugees, and patients with related traumas because no other professionals have the opportunity to frequently encounter the medical, mental health, social, and legal needs of this patient population (10). Although efforts to train and educate healthcare providers have been underway since the end of the 1990s, the Consortium is well aware that more work is needed at a local, national, and international level (10-11).

References:
1.United States Department of Health and Human Services. Administration for Children and Families. ACF Press Room.

2.United States Department of Justice. Immigration and Naturalization Service. 1997 Statistical Yearbook of the INS.

3.United States Department of Health and Human Services. Administration for Children and Families. Office of Refugee Resettlement’s 1997 Report to Congress.

4.Massachusetts Department of Public Health. Refugees and Immigrants in Massachusetts , 1999.

5.Sonis J, Gorenflo DW, Jha P and Williams C. Teaching of Human Rights in US Medical Schools. JAMA 276 (20):1676 – 1678.

6.Brenner J. Human Rights Education in Public Health Graduate Schools: 1996 Survey. Health and Human Rights 1996; 2(1): 129 – 139.

7. Rafuse J. Multicultural Medicine: "Dealing With a Population You Weren’t Quite Prepared For" Canadian Med Assoc J 1993; 148(2): 282 – 285.

8.Randall GR and Lutz EL. Serving Survivors of Torture. American Association for the Advancement of Science, 1991. p.55 - 70.

9.Eisenman D. Survivors of Torture in the General Medical Setting: How Common and How Commonly Missed VIII International Symposium on Torture – A Challenge to the Health, Legal and Other Professions, 22 – 25 September, 1999, New Delhi, India.

10.The Writing Group for the Consortium for Health and Human Rights. Health and Human Rights – A Call to Action on the 50th Anniversary of the Universal Declaration of Human Rights. JAMA 1998;280: 462 – 464.

11.Consortium for Health and Human Rights – Forging the Link Between Health and Human Rights. Available at:
http://www.phrusa.org/healthrights/index.html

The Need to Educate Patients About Their Symptoms

Several factors contribute to the alienation of refugees and survivors of torture. Among the most important are language barriers, cultural barriers, the lack of social support systems, and the incomplete understanding of the nature of these patients' psychological symptoms. As a result, refugees and survivors of torture struggle for years with a sense of insecurity and social estrangement that often lead to additional problems-including difficulties with work performance and feeling misunderstood, different, marked by trauma, and out of control (1-2).

Health care providers caring for this patient population should spend time explaining to patients the nature of their symptoms, the natural history of depression, anxiety, and posttraumatic stress disorder, and the different forms of treatment available. Because of the cultural stigma associated with seeing a psychiatrist or psychologist, this patient population mainly seeks care from primary care physicians
(1-2). Therefore, primary care physicians should not disregard their part in this crucial step in the rehabilitation of refugees and survivors of torture.  

References:
1. Randall GR and Lutz EL. Approach to the Patient. In: Serving Survivors of Torture. American Association for the Advancement of Science, 1991. p 55 - 70.

2. Shrestha NM and Sharma B. Torture and Torture Victims – A Manual for Medical Professionals. Center for Victims of Torture. Kathmandu, Nepal, 1995.