Title:When Global Health Is Local

Georgetown students and faculty offer medical support for D.C.-area migrants and refugees.

A woman in her 30s enters an examination room in a Washington, D.C., medical building, a look of quiet determination on her face. Because of the delicate nature and extensiveness of the evaluation, she will be here for three hours. While the duration is lengthy, she doesn’t mind the wait. The goal is to move forward with obtaining asylum in the United States—a process she started months ago. Ranit Mishori (M’02), professor of family medicine and (director of the Department of Family Medicine’s Global Health Initiatives) at Georgetown, is performing the evaluation.

Mishori leads the School of Medicine’s asylum program. Founded in 2014, the program is run by student volunteers who are paired with volunteer clinicians in the Washington, D.C., metro area. To facilitate the asylum application process, the program provides physical and psychological evaluations for asylum seekers. Getting approved for asylum—a legal process undertaken by forced migrants already in the United States—is an intricate and grueling process, sometimes taking years for people who have escaped perilous circumstances in their homeland.

“There are a lot of difficult pathways to seeking asylum,” says Megan Pogue (M’21), one of the medical student coordinators of the asylum program. “We are brought in when the lawyers determine that their clients warrant a physical and psychological evaluation.” The organization Physicians for Human Rights helps connect asylum seekers with clinicians who are trained to conduct the evaluations.

With demand outweighing the number of available clinicians, challenges quickly arise. “A lot of times there are delays in the process, causing a huge backlog of asylum seekers,” Pogue notes. “Many people wait for months and even years just to be evaluated.”

The asylum program hosts trainings twice a year for any clinicians interested in helping and performing evaluations. Demand is high for experienced clinicians who can conduct accurate assesments, Mishori says.

“It’s hard to recruit clinicians for this work because there’s a specific level of training necessary to carry out the evaluation,” says Mishori. “Some people dedicate time for one evaluation once every few months or whatever works in their schedule.

The time needed to perform an evaluation and then complete the legal affidavit for these clients is long. It is hard, tedious work.”

Recording Evidence of Abuse

Unlike a typical patient visit at a medical office, no clinical care is provided during an asylum seeker’s medical evaluation. It is part of a large process, requires impartiality, and is very technical. Lasting several hours or longer if the client does not speak English, the asylum exams are performed by clinicians who look for signs of trauma—both physical and psychological—that align with the individual’s personal accounts for seeking asylum. This means that asylum seekers must recount their abuse or torture history, along with the socio – political conditions that forced them to flee their country.

As asylum seekers recall their stories, clinicians like Mishori look for physical or underlying evidence of torture and illtreatment, such as scars, bruises, signs of genital mutilation, broken bones or teeth, and wounds.

Pogue reiterates the importance of medical evaluations as a way of improving the chances of asylum approval.

“The physical exam is one of the more important aspects because asylum seekers typically have very little evidence outside of their oral accounts. When we can show the trauma of what they’ve been through, it can improve their chances of being awarded asylum,” she explains.

High Demand, Anxiety, and Hope

Each year the Georgetown asylum program evaluates a growing number of migrants, totaling 60 since it began in 2014. As thousands of asylum-seekers in the D.C.-metro area await their application review, many still face hurdles as they race to escape life-or-death situations.

Shifting immigration policy around deportation creates stress and uncertainty, compounded by alarming stories of family separation and detention. Add in the challenges of learning a new language and culture, and the anxiety felt by many migrants is overwhelming.

“People who wouldn’t otherwise want to leave their country, but are forced to leave because of war and persecution, already face trauma,” says Mishori. “Then, the journey to get here is also perilous—from living in refugee camps to crossing borders.

And finally, they arrive and have to battle with acculturation, new climates, a new language, and so much more.”

Though there is still much work to be done as thousands await their number in line to be called, Pogue sees a glimmer of hope in the process of helping members of this community.

“It’s always rewarding getting the emails from lawyers, saying their client has been approved for asylum after years of waiting,” shares Pogue. “Even for us students, it’s incredible to see, because it shows that human rights has a place in medical education.”

From Forensic Exam to Primary Care

Although the asylum program provides one-time, impartial evaluations for asylum seekers, Mishori says that the initiative has expanded to promote continuity of care. The program now offers referrals to primary care physicians and to organizations offering broad support services for survivors of torture.

Navigating and maintaining primary care for the migrant community is a feat in itself. While the asylum evaluation process retraces an asylum seeker’s medical and physical health, it is solely for legal and forensic purposes and not intended to treat injuries or medical conditions. Forced migrants seen in the primary care setting may not recognize they suffer from posttraumatic stress disorder, says Mishori, but they show somatic symptoms, such as stomach pains and headaches. PTSD, depression, and anxiety disorders are some of the more common underlying conditions affecting forced migrants.

Culture and Community

Prior to embarking on a path in health and medicine, Mishori, who emigrated from Israel to the United States, worked as an international news producer in war-torn countries and conflict zones. Now, as she applies trauma-informed care to her work and advocacy for forced migrants and refugees, Mishori champions the provision of apt and culturally sound medical care for forced migrants, while training other health care providers she encounters to do the same.

“Having had the background in the news business, I consider the history of conflicts and issues in countries that many of these patients come from,” Mishori explains. “Putting that together with the patients’ symptoms, physical signs, and potential reasons as to what could have pushed them out of their country gives me a more comprehensive view of their health and well-being.”

She adds that the cultural differences between approaches to health—pain management and reliance on medications, confusing medical terminology in a new language, a complex health care system—present a jarring challenge for immigrant patients. With that in mind, Mishori opts for a holistic, cura communitas approach when ascribing primary care to immigrants transitioning into the American fold.

“Individual health is intricately bound with the health of family and community. Everything that happens in the community—your access to food, health, education, employment— affects your well-being, so it can’t just be about the person alone. It has to be about the community and population in which they’re affiliated.

“Issues of culture and acculturation are present,” says Mishori. “Regardless of the reason you migrate, it’s not easy to integrate and feel like you’re part of a new society.”

Providing evaluations for asylum seekers, and medical care for migrants and refugees, demands something extra from physicans and health workers. They must work to overcome language barriers, bring knowledge of political turmoil or conflict in other part of the worlds, and demonstrate sensitivity to cultural difference.

“Often times, the answers lie in the trauma these communities have undergone,” Mishori adds. “To build trust, and more importantly, to build awareness around the circumstance of asylum seekers is vital for physicians and health care providers in this work.”

• Migrants move from one country to another, for any reason, by choice or through force.
• Forcibly displaced persons have had to flee their homes, due to natural disaster, conflict, or persecution.
• Refugees are people fleeing conflict or persecution. They are specifically designated, and protected, according to international law as set by the Geneva Convention of 1951. Under current U.S. law, a person must apply for refugee status from outside the U.S. Sometimes large populations of refugees are granted the status as a group, when urgency is required and it’s impractical to conduct individual asylum evaluations.
• Asylum-seekers are individuals who are seeking international protection and are in the process of applying for official designation as refugees. Often they are already inside the country in which they hope to remain, or they are at a port of entry. Not every asylum-seeker is granted refugee status, but every refugee was at one point an asylum-seeker.
• Stateless people have no nationality, and thus struggle to access basic human rights.