Global Health: Medical Education and Training Help Torture Survivors Build a New Life
AAMC Reporter: September 2013
—By Eve Glicksman
Until hours before the Boston woman delivered her baby, not one of her physicians had noticed she had been the victim of genital cutting. The account comes from Jillian M. Tuck, J.D., who manages a national program at Physicians for Human Rights (PHR) to provide forensic medical evaluations for people seeking asylum.
In the United States, the number of torture survivors—half a million—is the same as the number of people with Parkinson’s disease, according to Steven H. Miles, M.D., professor of medicine at the University of Minnesota Medical School and chair of the university’s Center for Bioethics. “So shouldn’t physicians be able to recognize signs of torture the same way they would be expected to notice symptoms of Parkinson’s?” he asks.
Treating trauma stemming from human rights abuses can have significant benefits for a victim’s personal and professional life. But many physicians miss the signs that a patient has been tortured. Miles, who serves on the board of the Center for Victims of Torture in St. Paul, described an Eritrean immigrant who was in the emergency room (ER) for chronic pain. He said it was clear to him that the woman had been tortured and post-traumatic stress disorder (PTSD) was at the root of her pain and distress. At the ER, the staff treated her for pain, but did not refer her for the psychiatric care she needed.
“People come to the doctor with their symptoms, not their stories,” said James L. Griffith, M.D., professor of psychiatry and behavioral sciences at The George Washington University, who has worked extensively with torture survivors.
His observation is supported by a study published last year in Academic Emergency Medicine that followed 54 self-reported torture survivors who had sought care at the emergency department of a New York City teaching hospital. Among those who had experienced torture, three out of four said that no physician treating them had ever inquired about it. The authors of the research referred to torture as “an unrecognized public health concern.”
“Medical schools and teaching hospitals should be incorporating lessons into the curriculum for identifying and treating torture survivors,” Tuck said. Language can be a major barrier if English is not the patient’s first language. Other patients may not bring up their torture history because of feeling shame, wanting to avoid stigma, or not realizing treatment could help them. Still others may deny the impact of their abuse or wish to avoid discussing it.
Yet, simply asking someone who fits a risk profile for torture—a refugee from Africa or Tibet, where human rights violations are common, for example—often yields honest, reliable answers, Miles said. He recommends that physicians screen for a torture history if a patient from an immigrant group exhibits signs of depression or PTSD, complains of unexplained pain, or is known to be seeking asylum.
In an article Miles published last year in The Journal of Family Practice, he suggested this basic screening question: “Some people in your situation have experienced torture. Has that ever happened to you?”
Many torture survivors live in urban centers, so health care providers should not marginalize the problem, Miles continued. “Torture is one of those taboo areas [in medicine] that we need to learn how to do better.” Clinical education, research, and efforts to develop appropriate therapies for torture victims remain inadequate, he said.
Teaching medical students how to document torture
PHR hosts training sessions across the country for physicians on how to document evidence of psychological or physical torture for people seeking political asylum. Physician volunteers then conduct forensic evaluations—about 450 each year—of people referred to them by PHR.
“Many of the national trainers for this focused clinical area of expertise are in our teaching hospitals,” said Coleen Kivlahan, M.D., M.S.P.H., AAMC senior director of health care affairs, who is a PHR trainer and volunteer.
In 2010, PHR and Weill Cornell Medical College established a unique partnership to bring medical students into the loop. The student-run Weill Cornell Center for Human Rights (WCCHR) has medical students shadow attending physicians as they conduct the evaluations. Students are taught how to draft a medical affidavit, which is then verified by the supervising clinician.
Medical documentation often is a determining factor when a judge grants someone asylum. If there are discrepancies in the refugee’s story, for instance, a physician may note that cognitive disabilities caused by head trauma could account for inconsistencies.
A 2008 study of 2,400 asylum seekers published in the Journal of Immigrant and Minority Health showed that 90 percent who had medical documentation of past torture were granted asylum compared with 37 percent who lacked this evidence. In the Weill Cornell program, all 120 clients evaluated by WCCHR physicians were granted legal protection within the United States.
“We’re literally saving lives and providing students with an incredible learning experience at the same time,” said Ellie Emery, WCCHR executive director and fourth-year medical student at Weill Cornell.
The WCCHR has become the model for other universities looking to develop collaborations with PHR, including the University of Pennsylvania Perelman School of Medicine; University of Michigan Medical School; David Geffen School of Medicine at the University of California, Los Angeles; and Columbia University College of Physicians and Surgeons.
After the evaluations, the physician supervisors are careful to debrief students so they do not internalize the trauma and pain they witness.
“Shadowing these cases offers first-year students in particular a great introduction to clinical medicine. They hear stories that they are unlikely to hear elsewhere during their medical school education,” said Addie Goss, executive director of the Penn Human Rights Clinic (PHRC) launched in 2012 and a second-year student at the University of Pennsylvania Perelman School of Medicine.
The global mental health track
No evidence-based guidelines or standard curriculum exists for assessing and treating torture survivors, said Miles, who is teaching a graduate course on physicians and torture survivors this fall. The signs of physical and mental brutality can be invisible to an untrained eye, especially if the abuser took measures to hide physical evidence. Victims commonly suffer from PTSD and clinical depression, which may be accompanied by chronic pain syndromes, anxiety, and concussive head trauma. Standard interventions may include physical therapy, psychiatric medication, individual and family psychotherapy, and cognitive behavioral therapy to process and desensitize memories.
Nor do the problems of torture survivors end after asylum, noted Alisa R. Gutman, M.D., Ph.D., forensic psychiatry fellow at the University of Pennsylvania Perelman School of Medicine and PHRC medical director. “Leaving your entire family and culture behind can have a profound effect on mental health, sometimes more overwhelming than the torture.”
The Department of Psychiatry and Behavioral Sciences at The George Washington University (GWU) Medical Center offers a four-year Global Mental Health Track for psychiatry residents that includes the Program for Survivors of Torture and Trauma. In addition to following the academic curriculum, residents can train at a clinic in Northern Virginia where more than 150 torture survivors are treated each year. Residents in the track also can spend part of the year training in low- and middle-income countries and post-conflict settings of the Middle East, Africa, or Asia.
The emphasis in the Global Mental Health track is not so much on treating disorders as it is on treating patients within the full context of their family, religious faith, culture, and political or economic circumstances. At the clinic, staff have seen former Sandinista soldiers from Central America, survivors of the killing fields of Cambodia, Bosnian survivors of ethnic cleansing, Iraqi political prisoners, women gang-raped in the Congo, and Sudanese physicians who were advocating for human rights in Darfur.
Most refugees have experienced loss, trauma, and dehumanizing hatred. The biggest challenge for residents is to establish an empathic connection with the torture survivors without being overcome by the horror of their stories, said Griffith, who is interim chair of the GWU Department of Psychiatry and Behavioral Sciences.
“They are listening to accounts of electric shocks, beatings, endless interrogations, and families being forced to commit degrading sexual acts with each other in front of jeering soldiers or police.… It’s hard not to feel overwhelmed,” Griffith said.
Treating psychiatric and physical symptoms may be secondary, in fact, to the larger goal of restoring the torture survivor’s dignity, hope, and sense of a worthy life. Residents are taught how to treat people for demoralization, grief, loneliness, and humiliation, which often are more devastating than PTSD flashbacks and nightmares, Griffith said.
If there is a positive note, these survivors—many of whom have been leaders—may recover with surprising speed in treatment compared with people whose psychiatric illness is the result of genetic vulnerabilities or childhood deprivation, said Griffith. Nearly all those treated by GWU faculty and physicians at the clinic have experienced significant reductions in symptoms to the point where they can begin rebuilding their lives in the United States, he said.
“It is a powerful lesson for residents to witness how people can recover from extreme adversity,” Griffith summed up. “No matter how bad the torture was, some part of that person is intact. It’s the job of the clinician to find out who the person was before the torture and degradation—what mattered to him or her, what values and commitments were important—and build from that.”
"The biggest challenge for residents is to establish an empathic connection with the torture survivors without being overcome by the horror of their stories."
—James L. Griffith, M.D.