For refugees seeking asylum, medical exams are in short supply

ANN ARBOR, Mich. — They come from war zones and terrorist strongholds. From places where being the "wrong" religion, ethnicity or sexual orientation is a crime. From countries where sexual violence and mutilation are considered normal.

And after a long journey to America, tens of thousands of refugees every year begin another long journey: The legal process that offers their only chance of permanent asylum in the United States.

It can take years to get a verdict from the federal government. If their case isn't strong enough, they're deported.

Now, a new study shows how physicians and mental health professionals can play a crucial, objective role in this process, by examining refugees to document the scars of physical and emotional abuse.

But the study also highlights how many more such exams are needed, based on feedback from the lawyers who handle refugee cases. And that translates into a need for more medical professionals to be trained on how to do the exams, and then to volunteer their time to conduct them and write medical affidavits that become a formal part of the asylum case.

Even if the flow of new refugees decreases in coming years due to U.S. and United Nations policy changes, there are hundreds of thousands already here who are still building their cases.

The new research, done by a team from the University of Michigan Medical School and published in the Journal of Forensic and Legal Medicine, compiles information from a range of lawyers who help refugees on their asylum journey.

Such lawyers donate their time, or work for much less than they could otherwise earn, to compile the best case for why our nation should accept one more person.

But often, they told the researchers, that case is missing some of the most compelling evidence of what the applicant has suffered: an independent report on the mental and physical effects of what they endured back home. Whether that's a raised scar, the trace of a broken bone, or the telltale symptoms of post-traumatic stress disorder, the trained eye and ear of a physician is needed to detect them all.

Sixteen of these lawyers from around Michigan sat down with U-M researchers to talk in depth about how the results of medical exams factor in to their work, and what they look for in an exam when trying to make the best case on behalf of a refugee.

Most crucially, the attorneys said, independent, thorough and objective exams can provide corroboration for what the refugees tell the attorneys about their past. They can even reveal additional details. In rare cases, the physical signs conflict with the story that the individual has told their lawyer.

To be most helpful, the written medical affidavits must document an asylum seeker's physical and mental health in a way that attorneys and immigration officials can understand – not in the medical jargon that doctors usually use in their reports for one another.

The project grew out of the U-M Asylum Collaborative, a medical student-run organization that takes in requests for asylum-related medical and psychiatric exams from the organization Physicians for Human Rights and from the Freedom House asylum-seekers facility in Detroit. The students connect with U-M medical faculty who donate their time to conduct hours-long exams, and report their findings.

Michele Heisler, M.D., M.P.A., the senior author of the new study, is one of the group's faculty advisors and a professor of internal medicine at the Medical School with additional appointments in the U-M School of Public Health and the VA Ann Arbor Healthcare System. She serves on the board of Physicians for Human Rights, and has volunteered for the group since medical school. She's also a member of the U-M Institute for Healthcare Policy and Innovation.

Many of the asylum seekers also work with U-M Law School students and faculty to build the legal document that they file with the government.

U-M medical teams have completed such exams for more than 50 asylum seekers in the past two years. At least two of them have already succeeded in their quest for refuge.

The group offers an annual training workshop for medical professionals interested in getting involved. PHR also offers training in other locations.

The first author of the new study, third-year medical student Elizabeth Scruggs, notes that the idea to interview lawyers who work on asylum cases was the idea of the collaborative's founders, Anna C. Meyer, M.D., and Jamie VanArtsdalen, M.D., who have since graduated.

"Our sense was initially that there was great potential for an organization like UMAC to have an impact on people who are actively seeking asylum, but who couldn't afford or couldn't find a physician to perform these exams," says Scruggs. "But we also know that there are physicians who are interested in human rights and want to use their skills to help people who are going through the asylum process."

The authors note that there's potential for much more collaboration between the medical and legal professions around asylum cases.

"What was surprising was seeing how each lawyer handles their cases differently, and how each applicant's story is unique," says Scruggs. "So, a conversation between the doctor and the legal professional about each case, before the exam is very important. They need to connect before and even after, about the level of detail that's needed for an applicant to have a strong case, and the way the affidavit is written. They also need to understand any inconsistencies between what the exam shows and what the applicant has said. And the physician must be impartial."

Interestingly, some attorneys told the researchers that photos of refugees' scars might not be useful in asylum cases, because their quality and resolution can suffer during the process of evaluation by the relevant agencies. This can even weaken the applicant's case inadvertently.

The researchers did not look at whether the presence of a medical affidavit in an applicant's file increased their chance of receiving asylum, though the attorneys mostly said they felt it did. Previous studies in the last decade have suggested that asylum petitions with medical exam results do have a better chance of succeeding, but there is no definitive proof.

"The overwhelming response from the lawyers was that a medical exam was a necessary part of an application, that they always want it but they don't always have the 'luxury' of getting it at all," says Scruggs.

In cases where someone leaves their country without being able to take evidence of what they endured, the only documentation may be embedded in their body or their mind.


Reference: Journal of Forensic and Legal Medicine
Volume 44, November 2016, Pages 72-78,

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