Internists Support Global Human Rights, One Patient at a Time

It is impossible today to ignore the domestic political ferment about refugees and to be unaware of the global crisis. According to the United Nations, more than 258 million people worldwide are international migrants. Their plights move us: Africans drowned at sea while trying to reach the safety of Europe, displaced Rohingya fleeing genocide in Myanmar, Syrians fleeing a terrible civil war, and at our own southern borders the many who seek refuge in the USA from the violence of Central America.

Many of our patients have roots all over the world, and each new crisis or story of separated families reminds them of loved ones left at home, or of their own terrible journeys. Many US physicians and their families have also made this journey, and their experiences as strangers who found sanctuary here inform their professional and personal lives. Our histories resonate with these world events, and also fill us with anxiety, for these crises remind us of our own powerlessness to affect world affairs or domestic policies. In their excellent article “Asylum Seekers in a Time of Record Forced Global Displacement: The Role of Physicians,” McKenzie et al. offer physicians a straightforward manual on how to contribute, on an individual, case-by-case basis, to improving the lot of individuals caught in this global maelstrom.¹

As general internists and educators, the work of evaluating refugees who are petitioning for asylum in the USA calls on skills we possess, practice, model, and teach. This work contributes to social good but also enhances our skills as educators. Holistic clinical care looks at the patient from a social and experiential as well as physical point of view, incorporating principles of population public health as well as personalized medicine. The biopsychosocial model of patient interviewing and assessment comes into play as the physician gently interviews the traumatized refugee. Cultural competence is demanded as the patient/client is seen in the context of the political and social realities of the world they have fled. We are reminded of the precariousness of equal rights for women as asylum applicants flee from female genital mutilation (FGM), forced marriages, and domestic violence. Forensic skills, too rarely attended to in medical education, are challenged and honed as the physician examiner must correlate physical scars and disabilities with the abuses which may have caused them.

Evaluating asylum petitioners requires working in collaboration with lawyers, mental health professionals and other advocates for refugees, and asylum is one area where physicians can work together with legal advocates. The National Center for Medico Legal Partnerships is one example of the ways lawyers and physicians are coming together to collaborate on effective responses to social conditions which adversely affect health.²

Work with asylum seekers is also an excellent way to educate students and residents about Global Health and Human Rights. Health status and human rights are inextricably bound together. As Dr. Allen S. Keller, founder of the Bellevue Asylum Clinic, has noted, “Historically, in medicine and medical education, we have all too often focused solely on a disease-oriented model of health and illness. By considering the interrelationship between health and human rights, we are challenged to examine health within a broader context, such as that reflected in the World Health Organization’s definition of health as a ‘state of complete physical, mental and social well-being.’”³

We know that physicians who do not understand cultural determinants of health can fail despite the noblest of intentions, and a better understanding of patients’ social situations can help us address their needs. The stomach aches, headaches, anxiety, and pelvic pains of individuals suffering from PTSD may persist for a lifetime, and providers who do not recognize their patients’ histories miss valuable therapeutic opportunities. Although the refugees’ stories may be hard to hear, empathic listening is part of the path to healing.

Many countries restrict the professional independence of health care workers. Physicians around the world are sometimes constrained by their governments from practicing best medicine: think of the ways in which many countries denied the presence of HIV in their borders, or have delayed recognition of epidemics, or have imprisoned physicians who treat political prisoners or dissidents. In my work with asylum seekers, I have met public health nurses from Ethiopia and Myanmar, physicians from Sudan and Cameroon, advocates against FGM from Congo and Ethiopia, all of whom were persecuted by their governments for advocating for the public health. The mission of Physicians for Human Rights includes documenting the persecution of health care workers, and their website provides updates on the political restrictions of health care workers (http://physiciansforhumanrights.org/issues/persecution-of-health-workers/). We in the USA have the freedom to advocate for our patients, and we should exercise these rights to keep them vital.

Helping distressed refugees in the asylum process is a way for us to use our skills and compassion as physicians to help individuals and also to make a positive contribution to world health. The article by McKenzie, Bauer, and Reynolds in this issue encourages internists to expand their horizons and to apply their skills to assist asylum seekers seeking safety from persecution.