COMMENTARY

Evaluation and Treatment of Survivors of Torture and Refugee Trauma

Allen S. Keller, MD

Disclosures

May 13, 2009

In This Article

BT (Part I)

BT is a 22-year-old, French-speaking African man who studies accounting at the only remaining university in his country. Because of a civil war between his country's government and rebel forces, several hundred thousand individuals have fled their homes in the countryside to live either in vast shantytowns outside the capital city or in camps across the border in a neighboring country. When BT attends a peaceful rally protesting government corruption, he and several other demonstrators are arrested. BT is brought to a police station where he is interrogated about his political activities. He is repeatedly asked to name the organizers of the demonstration. BT is punched, kicked, and sodomized with a police baton. Subsequently, BT feels a hard object pressed against the side of his head. He then hears one of the policemen say to him, "Why shouldn't we just shoot you right now?" BT hears the click of a gun as the trigger is pulled, but nothing else happens. The policeman says to him, "Remember, it is very easy to die." BT is then struck on the back of his head and loses consciousness.

When BT awakens, he is in a small, dark, overcrowded, and foul-smelling cell. He feels sore all over his body. He is bleeding from the back of his head and from a right leg wound where he was kicked. BT is given very little to eat while in prison and constantly has stomachaches from hunger. BT's leg wound becomes infected, and despite repeated pleas, he receives no medical care. The only time BT leaves his cell is when he is taken every few days for further questioning and beatings. He often hears the agonizing screams of other prisoners.

After 3 months, BT is released when his family pays the police a bribe. He seeks medical care for his leg infection, which takes several months to heal. Later, after attending a meeting with several of the previous demonstration's organizers, BT sees police coming to his home. He runs and spends the night in hiding. Cautiously returning to his home early the following morning, BT sees that his house has been burned to the ground. He doesn't know what has happened to his family. Fearing for his safety, BT flees to a refugee camp located just over the border in a neighboring country. En route to the camp, BT sees the grisly signs of civil war: villages burned and dead bodies decomposing beside the road. He remains in the refugee camp for nearly a year. With the help of a friend, he obtains a US visa and an airplane ticket to New York City.

Introduction

Torture has received considerable public attention of late, including debates about whether torture is justified as a "necessary evil" in the war on terror. However, torture, which occurs in 100 countries worldwide, is primarily used by governments to intimidate and to silence opposition. An estimated 5% to 35% of refugees and asylum seekers have endured torture.[1,2,3,4] More than 400,000 torture survivors who fled persecution in their native countries are believed to reside in the United States.[5] Almost 2.4 million refugees from more than 110 countries entered the United States between 1980 and 2006.[6] A far greater number of immigrants to the United States have endured the trauma of war in their home countries, political violence, and traumatic refugee experiences.

BT (Part II)

In New York, BT lives in an apartment with 10 other Africans and works as a street vendor. BT's roommates notice that he is often coughing and suggest that he go to a local hospital. BT repeatedly refuses, fearing that police will be called when they learn that his visa has expired. BT also has a chronic headache, as well as stomach and musculoskeletal pain. He often awakens from nightmares in which he hears other prisoners or his family screaming, and then he is unable to fall back to sleep. He frequently experiences profound sadness, particularly when thinking of his parents and not knowing their fate.

Whether they realize it or not, many US healthcare professionals come into contact with immigrants, such as BT, who have endured torture and other traumatic experiences.[7,8,9,10] Although much of my time is spent directing a specialized program that cares for survivors of torture and refugee trauma -- the Bellevue/NYU Program for Survivors of Torture -- my work as an attending physician in the Bellevue Hospital Primary Care Clinic, in New York, NY, reminds me that such individuals may be sitting unidentified in our waiting rooms. If we don't ask, we will never find out this important information. The prevalence of torture survivors in primary care settings ranges from 7% to 11%.[8,9,10] One study conducted in clinics serving Latino patients found that 54% of those surveyed reported suffering some form of political violence in addition to torture in their countries of origin.[9] It is unlikely that individuals from war-torn countries, such as Iraq, the former Yugoslavia, or the Sudan, have not witnessed or experienced horrific events that could potentially affect their health.

Torture and other traumas suffered prior to arriving in the United States can have devastating health consequences on the physical, mental, and social well-being of immigrants. Fortunately, symptom relief and appropriate social and legal supports enable such individuals to recover the health and independence needed to rebuild satisfying, productive lives.

The Health Consequences of Torture and Refugee Trauma

When refugees and other torture victims flee, they leave behind their families, friends, homes, and professions -- in short, their entire lives. In some countries, people are persecuted for peaceful political or social activities, their ethnicity, religion, or their sexual orientation. Torture victims, such as BT, are often subjected to multiple forms of abuse, including beatings, mock executions, and imprisonment, under inhuman conditions.[10,11,12,13,14,15,16,17] Refugees who were violently forced from their homes may have escaped under harrowing circumstances. Many have faced not only extreme hardships, such as deprivation of food, shelter, and safety, but also the unsanitary and unsafe conditions in refugee camps. Those who make it to the United States face significant economic and social hardships, including unemployment or underemployment, loss of social status and connections, and language barriers.

The health consequences of BT's experiences are immense. His physical symptoms may be related to the abuse and poor conditions of his detention. Alternatively, these physical symptoms could be primarily somatic. BT suffers from severe psychological symptoms of depression and posttraumatic stress disorder (PTSD). He is worried about the safety and fate of his family and friends. He speaks almost no English, and despite being well educated, he works as a street vendor. "I feel like a ghost," he tells a roommate.

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