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msJAMA
March 7, 2001

Human Rights Violations and Refugee Health

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JAMA. 2001;285(9):1215. doi:10.1001/jama.285.9.1215-JMS0307-5-1

The United States is a nation forged by immigrants, most of whom chose to leave their countries of origin for personal, economic, or social reasons.1 Refugees and asylees, on the other hand, are immigrants who are forced to leave their homes because of persecution or threat of persecution. Because of the unique circumstances surrounding refugee and asylee patients, special attention must be paid to human rights issues when they are evaluated in a health care setting.

Of the more than 3.2 million refugees and asylees who have resettled in the United States since 1975,2 a significant proportion has experienced some form of torture.3 Two US surveys found that 5% to 10% of all immigrant patients seen in tertiary care hospitals, for example, had suffered torture in their countries of origin.4,5 These statistics probably underestimate the prevalence of torture by not representing individuals who opt not to come forward with their history of persecution.

Refugees and asylees suffer other human rights violations despite international law. For example, in violation of the 4th Geneva Convention, civilians now represent more than 90% of all casualties during armed conflicts; most of these casualties are children and women.6 Less recognized are the violations of social, economic, and cultural rights that many refugees and asylees may endure, such as lack of access to employment, education, medical care, and basic public health measures.

There are early opportunities for health care workers to determine if their patients have been exposed to human rights violations and to assess the effect these may have had on their health. Prior to departing for the United States, refugees will have received a health assessment to detect conditions that may preclude their entrance, such as active tuberculosis, human immunodeficiency virus infection, or leprosy.7 Refugees receive a similar assessment after they arrive in the United States. Although asylees, unlike refugees, do not receive mandatory health assessments, their attorneys may request, as part of an asylum claim, a medico-psychological evaluation to document sequelae of torture or related refugee trauma.8

Inadequate training of health care workers is a major reason why refugees and asylees often receive incomplete health assessments and inadequate primary care follow-up. Two surveys of US medical and public health schools found that only a small percentage of them teach about human rights violations and their relation with health.9,10

There are several ways of confronting human rights violation issues in the primary care clinic. Ideally, obtaining a history about a refugee or an asylee starts before the actual visit takes place. Providers should obtain some basic information about the patient beforehand, including his or her country of origin, the country's politicosocioeconomic conditions and prevalent health problems, and the population's cultural values. In this way, health care providers demonstrate a genuine interest in the patient that may help to eliminate patient distrust, which is an important barrier to giving care. Providers also close cultural gaps, avoid misunderstanding symptoms, and become more aware of the types of human rights violations that the patient might have endured.

Health care providers caring for refugees and asylees should maintain a high index of suspicion for conditions that are considered "exotic" in the United States but common in other parts of the world, such as schistosomiasis.7 A thorough physical examination, however, is also essential to detect the subtle marks of torture, such as scarring or radiological findings of previous trauma.11

Health care professionals should also be willing to work in multidisciplinary teams, including attorneys and other non-health professionals, to provide effective care for these patients. Refugees and asylees often struggle for years with language and cultural barriers, family reunification issues, and legal status problems in addition to health problems; an integrated approach where advocates work together will ameliorate these problems for the patient.

Refugees and asylees will continue to grow as a population as long as armed conflicts continue worldwide, and their complex needs are far from over once they have been resettled. Health care providers should receive adequate training to provide care for this vulnerable population and be willing to respond to their unique needs as victims of human rights abuses.

References
1.
US Census Bureau, US Census 2000. Available at: http://www.census.gov. Accessed November 17, 2000
2.
US Department of Justice, 1998 Statistical Yearbook of the INS. Available at http://www.ins.usdoj.gov/graphics/aboutins/statistics/ybpage.htm. Accessed November 17, 2000.
3.
Baker  R Psychosocial consequences for tortured refugees seeking asylum and refugee status in Europe. Basoglu  Med.Torture and its Consequences: Current Treatment Approaches Cambridge, Mass Cambridge University Press1992;83- 106
4.
Eisenman  DKeller  AKim  G Survivors of torture in a general medical setting. West J Med. 2000;172301- 304Article
5.
Randall  GLutz  E Serving Survivors of Torture.  Washington, DC American Association for the Advancement of Science1991;55- 70
6.
Krill  F The protection of women in international humanitarian law. Int Rev Red Cross. 1985;249337- 363Article
7.
Walker  PJaranson  J Refugee and immigrant health care. Med Clin North Am. 1999;831103- 1120
8.
Iacopino  VOzkalipici  OSchlar  C  et al.  Manual on the effective investigation and documentation of torture and other cruel, inhuman, or degrading treatment or punishment. Available at: http://www.phrusa.org. Accessed October 3, 2000
9.
Brenner  J Human rights education in public health graduate schools: 1996 survey. Health Hum Rights. 1996;2761676- 1678
10.
Sonis  JGorenflo  DJha  PWilliams  C Teaching human rights in US medical schools. JAMA. 1996;2761676- 1678Article
11.
Moreno  AGrodin  M The not-so-silent marks of torture. JAMA. 2000;284538Article
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