Lessons in health and human rights: providing dental care to torture survivors.

New York City has a large number of individuals seeking asylem who are victims of torture. In addition to dental needs, which include cases of severe trauma to the mouth, these individuasl require special support because of their fear of contact by those they do not know. A cooperative program between the New York University College of Dentistry and Bellevue NYU, known as the Program for Survivors of Torture, is described.

HIV screening and care for immigration detainees.

The detention of immigrants in the United States is a rapidly expanding endeavor with serious health consequences for the detainees. This detainee population represents non-criminal immigrants who are detained because of a visa violation or other immigration issue but who are not charged with any crime and do not enter the criminal justice system. HIV-positive detainees are especially vulnerable to lapses in proper medical care, and press reports have highlighted deaths and adverse medical outcomes among HIV-positive detainees. We have examined reports on detainee health issues published by numerous groups and conducted our own analysis of the health plan used to govern much of the specialty care for detainees who are HIV positive. We conclude that the system of immigration detention in the US fails to adequately screen detainees for HIV and delivers a substandard level of medical care to those with HIV. We provide several specific recommendations for improving screening and medical care among this highly vulnerable population.

The effects of torture-related injuries on long-term psychological distress in a Punjabi Sikh sample.

Torture survivors often report chronic debilitating physical and psychological distress. Prior research on the relationship between physical and psychological trauma suggests that the 2 are not independent. Injury sustained during torture may increase the likelihood of subsequent distress as either a moderator or mediator. For long-term psychopathology in a sample of Punjabi Sikh survivors of human rights violations (N = 116), chronic injuries mediated the path between torture and posttraumatic stress disorder, specifically the severity of numbing symptoms. Although injuries were associated with major depression, torture was not, and injuries did not moderate the relationship between major depression and torture. Chronic injuries may represent trauma severity or persistent traumatic cues. These findings emphasize connections between physical and psychological trauma and the importance of an interdisciplinary approach to torture treatment.

Predictors of suicidal ideation in treatment-seeking survivors of torture.

In this study, we examined sociodemographic, persecutor identity, torture, and postmigration variables associated with suicidal ideation in a clinical sample of 267 immigrant survivors of torture who have resettled in New York City. The purpose of this study was to identify variables associated with increased risk for suicidal ideation in survivors of torture before they receive legal, psychological, or medical services for torture-related needs. Results from a binary logistic regression model identified a combination of 3 variables associated with current suicidal ideation at intake into the program. Being female, having not submitted an application for asylum, and a history of rape or sexual assault were significantly associated with suicidal ideation at intake, when also controlling for several other important variables. The final model explained 21.4% of variation in reported suicidal ideation at intake. The discussion will focus on the importance of conducting a thorough assessment of suicidal ideation in refugees and survivors of torture.

Mental health of detained asylum seekers.

Asylum seekers arriving in the USA are likely to be held in detention for months or years pending adjudication of their asylum claims. We interviewed 70 asylum seekers detained in New York, New Jersey, and Pennsylvania. We used self-report questionnaires to assess symptoms of anxiety, depression, and post-traumatic stress disorder. At baseline, 54 (77%) participants had clinically significant symptoms of anxiety, 60 (86%) of depression, and 35 (50%) of post-traumatic stress disorder; all symptoms were significantly correlated with length of detention (p=0.004, 0.017, and 0.019, respectively). At follow-up, participants who had been released had marked reductions in all psychological symptoms, but those still detained were more distressed than at baseline. Our findings suggest detention of asylum seekers exacerbates psychological symptoms.

The impact of detention on the health of asylum seekers.

Asylum seekers arriving in the United States are often imprisoned for months or years while their asylum claims are processed. Recently, Physicians for Human Rights and the Bellevue/New York University Program for Survivors of Torture released the findings of the first systematic study examining the health of detained asylum seekers. The study found that the mental health of asylum seekers interviewed was extremely poor, including high levels of symptoms for anxiety, depression, and posttraumatic stress disorder, which worsened the longer individuals were in detention. The study also raises concerns about the manner in which asylum seekers are treated upon arrival in the United States and then while in detention. These findings support assertions that detention has a harmful effect on the health and well-being of asylum seekers. Policies regarding the long-term detention of asylum seekers should be reconsidered.

Effects of post-migration factors on PTSD outcomes among immigrant survivors of political violence.

This study examined the predictors of posttraumatic stress disorder (PTSD) in a clinical sample of 875 immigrant survivors of political violence resettled in the United States, with a specific aim of comparing the relative predictive power of pre-migration and post-migration experiences. Results from a hierarchical OLS regression indicated that pre-migration experiences such as rape/sexual assault were significantly associated with worse PTSD outcomes, as were post-migration factors such as measures of financial and legal insecurity. Post-migration variables, which included immigration status in the US, explained significantly more variance in PTSD outcomes than premigration variables alone. Discussion focused on the importance of looking at postmigration living conditions when treating trauma in this population.

Diversion of patients with mental illness from court-ordered care to immigration detention.

Over 350,000 immigrants are detained by U.S. Immigration and Customs Enforcement (ICE) each year. An unknown fraction of these detainees have serious mental illnesses and are taken into ICE custody even though a criminal court has ordered them to enter inpatient mental health care. The authors report findings from 16 such cases in which they have provided advocacy over the past four years. In some cases, they were able to secure release of detainees into inpatient care in community (nonforensic) settings, which involved substantial logistical challenges. Given the well-documented concerns about securing adequate care for ICE detainees with mental illness, a logical policy change would be for ICE to allow these patients to enter court-ordered inpatient care. This move would improve care for patients and would also unburden ICE from the untenable proposition of caring for patients that the criminal justice system has deemed unfit for incarceration.

Medical advocacy on behalf of detained immigrants.

Detention of immigrants by Immigration and Customs Enforcement (ICE) is a rapidly growing form of incarceration in the U.S. with almost 400,000 people detained in 2008 (Schriro in Immigration and Customs Enforcement, 2009, http://www.ice.gov/doclib/091005_ice_detention_report-final.pdf ). ICE detainees are predominantly from Mexico and Latin America and only a small minority of detainees are asylum seekers. Immigrant detainees lack a legal guarantee of medical care (unlike criminal arrestees and prisoners) and face challenges in receiving medical care, particularly those with chronic medical conditions (Venters and Keller in J Health Care Poor Underserved 20:951-957, 2009). Although we and others have long been involved in advocating for detained asylum seekers, few resources are dedicated to medical advocacy for the broader population of ICE detainees. At the NYU Center for Health and Human Rights (CHHR), a program of medical advocacy was initiated in 2007 on behalf of ICE detainees focused on improvement of care in detention and medical parole. Our preliminary efforts reveal a pressing need for more involvement by physicians and other health advocates in this area.

Posttraumatic idioms of distress among Darfur refugees: Hozun and Majnun.

Although psychosocial programming is seen as essential to the humanitarian response to the Darfur conflict, aid groups lack culturally-appropriate assessment instruments for monitoring and evaluation. The current study used an emic-etic integrated approach to: (i) create a culturally-appropriate measure of distress (Study 1), and (ii) test the measure in structured interviews of 848 Darfuris living in two refugee camps in Chad (Study 2). Traditional healers identified two trauma-related idioms, hozun and majnun, which shared features with but were not identical to posttraumatic stress disorder and depression. Measures of these constructs were reliable and correlated with trauma, loss, and functional impairment. Exploratory factor analysis resulted in empirical symptom clusters conceptually parallel to general Western psychiatric constructs. Findings are discussed in terms of their implications for psychosocial programming.

Screening for Torture: A Narrative Checklist Comparing Legal Definitions in a Torture Treatment Clinic.

Torture has been defined most precisely in legal contexts. Practitioners who work with torture survivors and researchers who study torture have frequently cited legal definitions, particularly those in the United States' Torture Victims Relief Act, the United Nations Convention against Torture, or the World Medical Association's Declaration of Tokyo. Few practitioners have operationalized these definitions and applied them in their practice. We describe how a New York City torture treatment clinic used a coding checklist that operationalizes the definitions, and present results. We found that in practice these definitions were nested; that using guidelines for applying the definitions in practice altered the number of cases meeting criteria for these definitions; and that the severity of psychological symptoms did not differ between those who were tortured and those who were not under any definition. We propose theoretical and practical implications of these findings.

Rates and impact of trauma and current stressors among Darfuri refugees in Eastern Chad.

Darfur refugees face hardships associated with chronic displacement, including lack of basic needs and safety concerns. Psychiatric research on refugees has focused on trauma, but daily stressors may contribute more to variance in distress. This article reports rates of past trauma and current stressors among Darfur refugees and gauges the contribution of each to psychological distress and functional impairment. A representative sample of 848 Darfuris in 2 refugee camps were interviewed about traumatic events, stressors faced in the camps, psychological distress, and functional impairment. Basic needs and safety concerns were more strongly correlated with measures of distress (rs = .19-.31) than were war-related traumatic events (rs = .09-.20). Hierarchical regression supported models in which effects of trauma on distress were mediated by current stressors. Although war-related traumatic events are the initial causes of refugees' hardship, findings suggest that the day-to-day challenges and concerns in camps mediate psychological distress associated with these events.

The immigration detention health plan: an acute care model for a chronic care population.

Immigration detention is the fastest-growing form of incarceration in the U.S. Numerous reports by advocacy groups and detainees themselves have alleged substandard medical care for detainees. We have undertaken an analysis of the health plan that regulates reimbursement of much of detainee health care. We conclude that this plan may place detainees at risk of receiving inadequate care, particularly if they have chronic medical problems or would benefit from routine health screening exams. We present several concrete measures that could immediately improve the level of medical care afforded to this vulnerable population.

Factor structure of PTSD symptoms among West and Central African refugees.

Although trauma is widespread in Africa, Africans are unrepresented in the literature on posttraumatic stress disorder (PTSD). The authors used confirmatory factor analysis of responses to the Harvard Trauma Questionnaire to model PTSD symptom structure in a sample of African refugees presenting at a U.S. torture treatment clinic. They tested four models that are proposed in the literature and one based on their clinical experience in which some symptoms of hyperarousal were integrated into intrusion. Their findings support a preference for a 4-factor aroused intrusion model. Discussion focuses on interpretation of models, the role of numbing and avoidance, and the limitations of Euro American symptoms in non-Euro American populations.

The subjective experience of trauma and subsequent PTSD in a sample of undocumented immigrants.

Although a subjective component of trauma is commonly recognized in diagnosing posttraumatic stress disorder (PTSD), there are few studies that specifically address Criterion A2, and none addressing this issue among undocumented immigrants. We assessed 212 arriving undocumented immigrants with diverse trauma histories to investigate concordance between objective and subjective factors of trauma (Criteria A1 and A2) and across different types of trauma and PTSD. Concordance between Criteria A1 and A2 varied, with highest rates found for political violence. Interpersonal violence in general was associated with higher rates of PTSD. We identified a dose-response effect for PTSD, but this was not dependent on other events (i.e., other doses) meeting Criterion A2. Discussion focuses on Criterion A within the phenomenology of PTSD and the need to gauge subjective interpretations of trauma events among this population.

Torture in Abu Ghraib.

Iraqi detainees subjected to torture and mistreatment at Abu Ghraib prison may continue to suffer from significant physical and psychological consequences of their abuse. This article reports two cases of Iraqi individuals allegedly tortured at Abu Ghraib. Detailed forensic evaluations were conducted approximately one year after their abuse in accordance with international guidelines. The findings of these evaluations substantiate their allegations of torture and confirm the profound health consequences of torture. Furthermore, these cases support assertions that abuse of prisoners was not limited to being perpetrated by guards, but also occurred systematically in the context of interrogations. These cases also raise concerns about inadequate medical care for Iraqi detainees.