;)
Figure: torture survivors
Lars Beattie, MD, remembers the night he first realized victims of torture were living in the United States. He recalled being stunned by that information, and a sense of that initial reaction is still apparent when he tells the story nearly 20 years later.
A colleague in the emergency department at Elmhurst Hospital in Queens, NY, treated a patient who presented with severe jaw pain and a malocclusion. “How did that injury happen?” Rajeev Bais, MD, asked the patient. “It looks like it was long ago.”
The young man, an immigrant from Liberia, explained that he had been tortured during the country's civil wars in the late 1990s. “The soldiers smashed my face with a rifle butt after shooting my father and my wife,” he said.
“What do you do with that?” Dr. Beattie said he and Dr. Bais asked one another. “We were stopped in our tracks. Motrin isn't going to do much for the permanent jaw fracture that's healed in a way that prevents him from eating much of anything other than milkshakes. The initial plan to refer him to the oral and maxillofacial surgery clinic wouldn't fly. Without a legal claim to be in the country, and if his status came to light, he would probably have been deported and sent back to the country that tortured him, as is the case for any survivor of torture if they are unable to get asylum.”
The ED as Refuge
The Center for Victims of Torture estimates that as many as 1.3 million survivors of politically motivated torture live in the United States. (https://bit.ly/39foeki.) And as Dr. Beattie discovered, many survivors of torture seek medical care in the emergency department.
He and his colleagues conducted a cross-sectional survey of patients presenting to the Elmhurst emergency department. Patients who consented to participate were asked if they had ever been threatened or harmed by groups such as the government, police, military, or soldiers and whether they or their family members had ever experienced torture. (Acad Emerg Med. 2012;19[10]:1158; https://bit.ly/3sp6dr9.)
Fifty-four (11.5%) of the 470 study participants reported having experienced torture. Nine (16.7%) had ongoing physical disabilities, 30 (55.6%) had recurrent intrusive and distressing memories, 42 (77.8%) never had a physician inquire about torture, and only eight (14.8%) had requested political asylum. Twenty-nine (53.7%) of the self-reported survivors met the definition of torture set by the U.N. Convention against Torture, meaning that more than six percent of ED patients surveyed had endured torture. (Acad Emerg Med. 2012 Sept 25;19:1158; https://bit.ly/3sp6dr9.)
These cases inspired Drs. Beattie and Bais to establish the Libertas Center for Human Rights, which provides services to survivors of torture through Elmhurst Hospital's ED with a primary
focus on conducting forensic evaluations and providing affidavits in support of clients' asylum applications. “These people, with their experiences, often wanted to remain somewhat invisible,” Dr. Beattie said. “And with no legal status, no ability to gain employment, pay taxes, or obtain health insurance because they have fled horrific experiences in their country, how do they plug into the health care system? They don't. So they end up in the one place in health care where there are no barriers to entry, and that's the emergency department.”
Elmhurst has a particularly large immigrant population, and is one of the most ethnically diverse neighborhoods in New York City. Approximately 71 percent of the residents and 62 to 68 percent of those in its neighboring communities of Jackson Heights and North Corona, respectively, were born outside the United States. (Office of the New York State Comptroller. October 2019; https://bit.ly/3stsnJa.) New York City is home to a disproportionate number of torture survivors; it had 8811 asylum cases completed and 4830 applicants granted asylum, representing 55 percent of all U.S. asylum grants in 2014. (TRAC Immigration. https://bit.ly/2NSIWPz.)
Plan of Action
Emergency departments that serve areas with smaller immigrant populations may be less likely to have significant numbers of survivors of torture coming through their doors. But many cities and towns beyond New York City still have substantial immigrant communities where emergency physicians may encounter torture survivors. Consider Cincinnati, Miami, and Birmingham, AL, where more than 87 percent of population growth between 2014 and 2017 was due to new immigrants. In fact, immigrants contributed to nearly 33 percent of total population growth in the top 100 metro-politan areas in the United States from 2014 to 2017. (New American Economy Research Fund. July 10, 2019; https://bit.ly/2OZ3FBX.)
Among those growing immigrant populations are likely significant numbers of people who have endured physical and mental horrors similar to those experienced by that patient of Dr. Bais. Emergency physicians nationwide are in a uniquely important position to make a difference in identifying torture survivors and ensuring that they receive appropriate care and services, said Allen Keller, MD, an associate professor of medicine at the New York University School of Medicine, a founder of the Bellevue/NYU Program for Survivors of Torture, and the director of the Center for Health and Human Rights at the NYU School of Medicine.
“The ED is often the first and sometimes the only place where many of these individuals will present for care,” he said. A survey that Dr. Keller and David Eisenman, MD, a professor of medicine at UCLA, did find that 6.6 percent of patients who weren't born in the United States and who presented to an adult ambulatory care clinic were survivors of torture, but none had been previously identified by their clinicians, including emergency physicians. (West J Med. 2000;172[5]:301; https://bit.ly/31gdOg1.)
Emergency physicians should be prepared for survivors of torture to present to the ED, Dr. Beattie said, noting that EPs are often best placed to encounter and identify these folks, largely because the ED has the fewest barriers and is a natural venue for them to seek care. “This is something we term the ‘critical encounter’ for these individuals,” he said.
Emergency physicians should also learn how to identify potential survivors of torture and provide them with appropriate care and referrals. Start by learning where torture is prevalent. “Torture has been documented in about 132 of the 195 countries in the world,” Dr. Beattie said. “But if you have a sense of the current war zones and regions where people are experiencing torture in the current environment, and you have a patient who comes from one of those regions—Syria, Yemen, Ethiopia, Democratic Republic of the Congo, Somalia, Afghanistan, Sudan, El Salvador, amongst many others—that's something to pay attention to.”
Medical Consequences
EPs should also understand the medical sequelae of torture, most commonly musculoskeletal complaints and head pain. Almost half of 139 asylum seekers presenting to the Human Rights Clinic of Miami reported a history of head injury. (Neurology. 2020;95[19]:e2605.) Persistent gastrointestinal symptoms can also result from imprisonment in crowded, dirty cells, and many survivors of torture experience severe ongoing psychological distress that can produce physical symptoms like head and stomach pain. (The Center for Victims of Torture. https://bit.ly/3lWAife.)
The most important thing clinicians can do is establish trust and rapport, said Dinali Fernando, MD, MPH, the executive director of the Libertas Center. “We in the ED have to often do it in a very short time frame without the luxury of privacy and quiet, but that's part of the skill set we have to develop anyway. We have only six rooms in our whole ED, and most separation is via curtains. But I pull those curtains closed to have some sense of privacy and elevate the bed as high as I can, so that I'm not looking down at the patient but am speaking at eye level.”
It can be difficult for survivors of torture to disclose their experiences, Dr. Keller said. “There is a lot of fear and shame involved: fear of reliving an event, fear of endangering family and friends still in the country, fear of being deported,” he said. “People can feel shame over being a victim, and sometimes injuries can be intentionally inflicted to create shame, such as those that are sexual in nature.”
Dr. Fernando advised EPs to ask patients nonjudgmental, open-ended questions, like what made them leave their country. “Libertas patients have often told us they'd be hesitant to bring up their torture history on their own, but if someone asks them, they would be willing to talk about it,” she said. “They have often carried their trauma for years and the ability for them to unburden themselves and for us to bear witness and normalize their symptoms after such trauma in itself can be therapeutic.”
Resources and Support
Dr. Beattie said emergency physicians must reassure them that there will be no legal or immigration consequences to their disclosure. “The United States has lost a lot of credibility as a safe place for asylum seekers in recent years,” he said. “These patients need to be reassured that you are their doctor, that your conversation is protected by the doctor-patient relationship, and nothing discussed will be reported to the police or immigration officials.”
Another good idea: Know the resources in your area for survivors of torture. Regional groups that support survivors of torture, like Libertas, can connect these individuals with legal representation to help them through the asylum process and provide social and psychological support and other services,” Dr. Beattie said. “These types of things aren't covered by emergency medicine boards, so that's where the social worker in one's department can help the whole practice group out. It's important to ensure department social workers are aware of the issues and know about existing community resources that serve this population.” Other regional groups where torture survivors can find support can be found at https://healtorture.org.
Another way to make torture survivors feel comfortable is to inform them that they are in control. “Tell them you want to connect them with services and professionals who can help them, but let them know that it is always their choice to use any information and options you give them,” Dr. Fernando said. “These are individuals who have had all sense of control stripped from them. It is important to empower them to regain control over their lives.”
Emergency physicians interested in helping survivors of torture can contact Physicians for Human Rights, which has a program to train volunteer medical evaluators to participate in preparing medical affidavits for asylum courts. (https://phr.org.) “This work is invaluable,” Dr. Keller said. “Medical documentation can make all the difference in an asylum application, and our ED training is very broad, so we are very well suited to work on these applications.”
“It's not just an opportunity for us, but our responsibility to identify these patients so we can help them get connected to the wraparound services they often need,” said Dr. Fernando. “I'm fully aware that we are so short of time in the ED, but we have access to these populations in a way that no other specialty has because the ED is often the portal of entry into the health care system for vulnerable populations.”
She said these individuals were often persecuted because they were leaders, advocates, missionaries, educators, journalists, and photographers. “They are incredibly resilient, and given the opportunity to get back on their feet, they have so much to contribute to our society,” Dr. Fernando said. “As an ED provider, if you can help with that process, you can truly change their lives.”
Dr. Keller agreed. “There is nothing we can do to undo what happened to these people, but [there's] a lot we can do to help rebuild their lives,” he said. “That's really gratifying and why we went into medicine in the first place.”
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Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work atwww.writergina.com.
