Asylum Medicine: A Call to Respond

Over the past year, the subject of migration has rarely left the headlines. But relatively little of the media coverage has had the substance it merits – particularly on the issue of asylum. We’ve been immersed in a political back and forth that too often ignores the lives of those caught in the middle.

I still vividly remember the first asylum seeker I met as a physician. At the time, I was a volunteer for Doctors of the World-USA (now HealthRight International), a program that trains doctors on how to conduct forensic medical and psychiatric examinations of asylum seekers with claims of torture or other forms of persecution. Through the organization, I learned about the man’s background before meeting him. He had been imprisoned and tortured after standing up for the rights of others in his home country. Soon after, he escaped and eventually made it to the United States to apply for asylum. Honestly, I cannot recall if he entered the country legally or illegally. It was irrelevant to my duties.

I was living in Brooklyn, New York, at the time and took the subway to a large hospital in Manhattan, where the man and I were scheduled to meet. We were both a little nervous, not knowing exactly what to expect. Determined to be thorough in my evaluation and documentation, the interview and physical examination took us hours to get through. He had numerous scars, and one scar on his abdomen was virtually diagnostic. The large scar took the shape of an object many of us use every day. His captors had burned him with it. Due to the burn, he had areas of skin where he could not feel the touch of a hand and other areas that were hypersensitive to light touch. Although I took forensic photographs for his attorney and the immigration judge, I would never need a picture to remind me of the burn’s semi-triangular shape and the mangled scar left behind. That scar and the man’s wounded face as he told me about how he was tortured are permanently etched in my memory.

After completing the asylum evaluation and providing a medicolegal report for the man’s attorney, I never saw him again. Much later, I was informed that he legally qualified for asylum, in part because of the report I provided. He would not be forced to return to a place where he would have likely suffered further persecution, including perhaps death. Nonetheless, I knew he would continue to be at risk for suffering from the psychological consequences of torture. What would he think of every time he saw that abdominal scar in the mirror? I hoped he would at least reflect on his courage and the way he rose up after incredible tragedy.

That first asylum evaluation was about 17 years ago. Since then, I’ve performed forensic medical and psychiatric evaluations of many other torture survivors seeking asylum and trained other healthcare professionals on how to do the same. Several years ago, with dear friends and colleagues, I helped launch an asylum medicine clinic in Washington, DC. And recently, two colleagues and I penned a paper on asylum medicine standards and best practices, hoping to stir further dialogue in this area. One of my coauthors, Amy Zeidan, is an emergency medicine physician who has conducted numerous asylum evaluations. Her first experience sitting in on an asylum evaluation took place when she was my medical student. During a recent training for other healthcare professionals, I was touched to hear her cite my words from years before – that practicing asylum medicine is one way a doctor can save a life. Just out of fellowship, she has already emerged as a leader in the field. We need so many more like her – and like my other coauthor, Katherine McKenzie, an internist who heads an asylum medicine clinic at Yale School of Medicine and trains medical students and residents on the forensic evaluation of asylum seekers.

Today, there are even more people seeking asylum in the United States and elsewhere than there were when I first began conducting asylum evaluations. Worldwide conflict and violence have driven global displacement to record numbers. In the United States, applications for political asylum have increased while the number of people granted asylum has decreased. The United States hosts far fewer asylum seekers and refugees than many other countries, including much poorer nations.

According to United States and international law, people have a legal right to seek asylum. And the bar is fairly high – in order to qualify for asylum, applicants need to show they have suffered or will likely suffer torture or other forms of persecution in their country of origin based on political opinion, race, religion, nationality, or membership in a social group. Since physicians and other healthcare professionals can document physical and mental evidence of torture, we have a critical role to play in the evaluation of people seeking asylum. Unfortunately, the demand for asylum evaluators currently far exceeds the number of doctors and other clinicians prepared to conduct forensic evaluations.

So, in an effort to bolster the number of qualified healthcare professionals who can conduct asylum evaluations, my two colleagues and I summarized standards and best practices in this emerging area of medicine. In press via Harvard’s Health and Human Rights Journal, the paper is open access for anyone who wants to read it or use it as a resource.

Even if you aren’t a healthcare professional, I hope you will take the time to review the paper and share it widely. At a time when more global citizens are at risk for torture and other human rights violations, it is critical that we set the facts straight about asylum law and asylum seekers. Perhaps you could better inform a family member, friend, colleague, or policymaker about the plight of asylum seekers. Or, if you have a doctor, perhaps you could gauge their interest in asylum medicine and point them to the paper to learn more.

With tremendous gratitude to the asylum seekers I have met over the years – including one man I met in New York 17 years ago – I have been humbled by their stories. They have taught me incredible lessons about adversity and what it takes to overcome our collective human history of violence. And they have deepened my sense of justice, patriotism, and compassion through their own.