This is the seventh edition of the EthnoMed newsletter. Click here to view previous editions.
A message from Medical Director, J. Carey Jackson, MD, MA, MPH:
CLINICAL CARE FOR SURVIVORS OF TORTURE
Recently, a 36 year old mother with two children resettled in Seattle after relocating from Nairobi where she lived with her kids as a refugee for several years. She arrived thin, wasted, and fatigued. After being here only a matter of weeks she became short of breath, and began to cough up blood. It became evident in her evaluation that she had a lung mass and relatively advanced HIV. This was unexpected news to her and her questions about possible sources of infection revealed the following history.
Her husband and two of her four children were burned to death in their new home by rioting villagers acting against her ethnic group. She was captured and held prisoner for 5 days in the hospital where she worked. She was humiliated, serially raped, and beaten. She escaped from the hospital and the city in a West African country to Kenya, leaving her children in the care of her mother until she could send for them. She sent for them before planned because men dismembered her mother with machetes in front of these two surviving children, leaving them numb and dissociated.
A 42 year old Oromo woman was held by civil authorities in Ethiopia and accused of resistance activities, along with her brother and father. She was held in a cell for weeks with many other people. There was only room to stand, and people slept when sitting, and sat in shifts. She witnessed beatings, mock executions, and a person who had their face plunged into boiling water. She saw women dumped unconscious following sexual assault and beatings by the guards. She was threatened with rape and death and she was knocked unconscious by blows to the head. She was humiliated, and starved.
A 76 year old Vietnamese man recounts how as a soldier working with the CIA he was captured , shackled, chained, and held in prison for 22 years, 19 of these in solitary confinement. He was rarely interrogated, but starved routinely, confined to a small space, and kept in a crouched position for years.
These three people share in common experiences that meet criteria for torture. Sadly, 200 of the world’s nations torture their citizens or prisoners. We typically think of torture as acts of physical violence perpetrated during an interrogation with the intention of producing information, as in the recent movie “Zero Dark Thirty” where the CIA water boarded suspected terrorists to produce information about Bin Laden. But the definition held by the WHO and UN is much broader than this and includes imprisonment, forced labor, threats, and witnessing the violation of others. When these acts are perpetrated against an individual “under color of law“(meaning that one could not appeal to authorities because they are complicit in the acts of violence), then it is torture.
In general we avoid dwelling on images and discussions of unspeakable cruelty. We may abstract them as PTSD or depression for the patient chart, but through these abstractions we may lose the critical details of use to us in the patient’s care. A history of torture in all these cases is relevant for therapeutic reasons. Occasionally, there is a history of traumatic brain injury or sexual assault that remains unreported because the attendant memories are painful. In these cases diagnoses are missed and painful sequela unaddressed. Occasionally, patients are uncooperative with evaluations that remind them of the conditions under which they were tortured, pelvic exams for those sexually assaulted, MRI scans for those held in forced postures, restrained, or kept in isolation. On rare occasions physicians themselves are the perpetrators of the torture as during forced abortions or disorienting medications or intoxications. In these situations attempts to help which include procedures and medical technologies may unwittingly re- traumatize individuals. Knowing the history can smooth the process, prepare the patient, alert technicians, or allow for therapeutic alternatives to avoid further trauma. When a patient acts out, is uncooperative, lost to follow-up, or deteriorating the history of torture is sometimes a relevant place to explore. The history is not always relevant; still it is important to know any complicating details that can impact a patient’s care.
Rough estimates suggest that as many as 10% of all immigrants have had experiences that meet criteria for torture, these numbers are much higher among refugees, especially those from certain countries like Eritrea, Iraq, or Congo. Patients would like to forget these humiliating histories and may believe these experiences can be left in the past. Unfortunately, these memories often resurface when situations of vulnerability and powerlessness provoke parallel feelings or memories as in a new cancer diagnosis, a car accident, or the loss of a loved one.
These experiences are common among refugee from around the world, from countries not typically included in EthoMed pages such as China, India, Iran, and El Salvador. There are now new pages within EthnoMed dedicated to providing reminders for clinicians on the relevance of torture and how to take the history. There are a broad range of resources available. There is information on traumatic brain injury, electric shock, and on Post Traumatic Stress Disorder. Many people feel humiliated by the experience of torture and do not readily bring it up. A thoughtful clinician can unburden them by carefully soliciting the history and showing them the importance and relevance of these historical facts to their ongoing care. There are also links to other web sites with helpful resources.
The mother with blood tinged cough was stabilized in a manner that helped eliminate the possibility of tuberculosis and allowed her to prioritize attention to the trauma her children had suffered. The Oromo woman was treated for traumatic brain injury, PTSD, and encouraged to tell her story which she desperately wanted to do. The leg injury from trauma and the forced postures of 19 years in solitary confinement was managed with the heroic experience of imprisonment, starvation, and isolation in mind. In each case it was knowing the history of torture that helped shape the treatment plan. Those of us who work with survivors of war and torture do our patients a great service when we know this detailed history and help them work with it when necessary.
OF INTEREST ON ETHNOMED
Caring for Survivors of Torture - Selected Resources
Evaluation and Treatment of Survivors of Torture A PDF slideshow developed by Drs. J. Carey Jackson and Nicole Chow Ahrenholz to help clinicians who treat victims of torture recognize the significance of this history, know how to record and document it, and how to integrate this history into medical decision making.
Obtaining Survivor Histories - Video Clips and Clinical Pearls Short video clips give examples of issues to be aware of when obtaining a patient history. These clips are from an interview with a patient of Dr. Carey Jackson (used with permission) demonstrating aspects of torture histories commonly encountered among torture survivors, including: chronic nightmares and sleeplessness, starvation, distorted timelines/memory loss, and confinement.
Becoming Empowered Africans Through Improved Treatment of Diabetes, Hepatitis B, & HIV - August 19th-21st
An educational training Aug 19-20th for healthcare providers who work with African clients around issues of diabetes, Hepatitis B, and HIV. Topics include effective strategies to improve patient-provider communication and adherence to treatment. Additional training Aug 21st for client education.
2014 Washington State Coalition for Language Access (WASCLA) Language Access Summit - October 24th-25th
A 2 day language access summit, Oct 24-25, 2014, in the greater Seattle area.
Ashura 2014 - November 3rd (estimated)
The Day of Ashura (عاشوراء (ʻĀshūrā’, Ashura, Ashoura, and other spellings) is on the 10th day of Muharram in the Islamic calendar. Several narrations point to the significance of this day from the earliest of times. Commemoration of this day includes fasting.
EthnoMed was founded in 1994 and is a joint program of the University of Washington Health Sciences Library and Harborview Medical Center in Seattle, Washington. EthnoMed grew out of another hospital program, Community House Calls, which was successfully bridging cultural and language barriers during medical visits, through interpretation, cultural mediation and advocacy with immigrant patients, families and communities. The website was created to reflect and support that experience. In recent years, our content has expanded to reflect many new communities that have settled in the Seattle area.
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