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THE MEDICAL EVALUATION OF THE ASYLUM SEEKER : 

THE MEDICAL EVALUATION OF THE ASYLUM SEEKER Richard Kovar MD FAAFP Medical Director, Country Doctor Community Health Centers

THE PROBLEM-deteriorating access to asylum in US : 

THE PROBLEM-deteriorating access to asylum in US Protocol Relating to the Status of Refugees (1967) Refugee Act (Immigration and Nationality Act (1980) Illegal Immigration Reform and Immigrant Responsibility Act (the “1996 law”) 9/11

WHY DO THIS? : 

WHY DO THIS? Reaffirm American tradition of welcoming those fleeing persecution Chance to assist some of the most unfortunate, dispossessed people on Earth Give voice to pain and suffering of victims of human rights abuses Life or Death issue!

WHO SEEKS ASYLUM? : 

WHO SEEKS ASYLUM?

THIS IS NOT PRIMARY CARE : 

THIS IS NOT PRIMARY CARE Objective medical a/o psychological evaluation to facilitate due process NOT advocacy work Correlate person’s story with the examination Avoid primary care (can hurt the case)- must maintain professional credibility OK to provide care if asylum granted

“The purpose of written reports is to assess claims, document evidence of torture and ill treatment and effectively communicate this evidence to adjudicators. The purpose is not to prove or disprove the applicant’s allegations of abuse. The health professional provides expert opinions on the degree to which the findings correlate with the applicant’s allegation of abuse.” (PHR Manual) : 

“The purpose of written reports is to assess claims, document evidence of torture and ill treatment and effectively communicate this evidence to adjudicators. The purpose is not to prove or disprove the applicant’s allegations of abuse. The health professional provides expert opinions on the degree to which the findings correlate with the applicant’s allegation of abuse.” (PHR Manual)

PRO BONO : 

PRO BONO Doesn’t work in FFS system (no resources/logistics are complicated) If you decide to charge, make that clear to attorney Attorney services may or may not be pro bono

LOCATION : 

LOCATION Your office ICE facility ?other

BACKGROUND OF EXAMINER : 

BACKGROUND OF EXAMINER Prior experience with immigrants/refugees Training (PHR, mentor,manuals, medical literature Resume (update before getting started) Interest/knowledge of world events Ability to compartmentalize (this is very difficult work!)

MEDICAL OR PSYCHIATRIC EVALUATION : 

MEDICAL OR PSYCHIATRIC EVALUATION Depends on qualifications Time issues (Mental Health evaluation takes more time)

LOGISTICS : 

LOGISTICS Discuss with attorney- must have easy, open communication Ask for declaration ahead of time (may be rough draft) Ask for country report if available (HRW, AI) Schedule enough time (60-90 minutes)

LOGISTICS- continued : 

LOGISTICS- continued Translation issues (licensed interpreter may not be realistic) Prepare your staff NO INTERRUPTIONS!!

TEACHING PROGRAMS : 

TEACHING PROGRAMS Resident Evaluations OK if signed by qualified evaluator

THE EVALUATION : 

THE EVALUATION Introduce yourself and your role/acknowledge discomfort Careful review of issues in the declaration Ask if other abuses not in declaration Investigate other scars found on exam Document all physical evidence/findings or lack thereof Measure and record all findings

SUPPLIES : 

SUPPLIES Basic Exam Room Good light Tape measure Ophthalmoscope Magnifying glass Speculum/ Anoscope

PHOTOGRAPHY- Digital Ideal : 

PHOTOGRAPHY- Digital Ideal Quality better than Polaroid Fast printing Edit Save on disc or files Back it up!! Print/ label and # photos

CONCLUSION OF INTERVIEW : 

CONCLUSION OF INTERVIEW Explain what you will do next Reaffirm confidentiality Obtain contact info Wish them best of luck!

THE WRITTEN REPORT : 

THE WRITTEN REPORT The Goal: To provide expert opinion on the degree to which the findings correlate with the allegations of torture or abuse Qualify yourself as an expert Be Meticulous: Details are critical Follow chronological sequence of events-stay organized

WRITTEN REPORT -continued : 

WRITTEN REPORT -continued Documentation of physical evidence (head to toe) Review sample affidavits Number paragraphs

WRITTEN REPORT-continued : 

WRITTEN REPORT-continued Describe where, when, why evaluation occurred Describe language/translation issues Describe your qualifications- do not reference resume Document only the facts: DO NOT SPECULATE! Your professional credibility is being evaluated as well MAINTAIN OBJECTIVITY AND IMPARTIALITY

ORAL TESTIMONY : 

ORAL TESTIMONY Have lawyer prepare you for testifying and cross-examination Clarify your time constraints (the court tries to be flexible) Review the case beforehand Use your Palm Pilot reminder function

APPROPRIATE LANGUAGE : 

APPROPRIATE LANGUAGE Consistent with/ highly consistent with Not consistent with Typical of Diagnostic of Non-specific Again, do not speculate

SUMMARIZE FINDINGS : 

SUMMARIZE FINDINGS Give your professional opinion Address credibility of client Step back and put it all together Comment on absence of physical evidence when appropriate The history of a lesion that leaves no scar is important

LOGISTICAL PROBLEMS : 

LOGISTICAL PROBLEMS Need for specialist Need for radiology support Asylum seeker needs medical care Shame, trust,fear issues may interfere (especially fear for family members)

COMMON TYPES OF TORTURE AND ABUSE : 

COMMON TYPES OF TORTURE AND ABUSE Beatings/ blunt trauma/whipping Mock execution Sensory Deprivation Rape/ sexual abuse Electrical Shock Suspension Burns (hot metal, acid, burning sticks) Gunshots Stabbing Hacking Falanga

FEMALE GENITAL MUTILATION (FGM) : 

FEMALE GENITAL MUTILATION (FGM) Knowledge of cultural norms Regional/ tribal variations Clitorectomy Infibulation Complications Do not photograph

SCARS : 

SCARS Most injuries heal within weeks to months Scars often very non-specific Location often more important than appearance Opinion re: Accidental, inflicted, self-inflicted, 2nd to illness or disease, vaccinations

MEMORY PROBLEMS : 

MEMORY PROBLEMS Closed head injury/ organic brain syndrome Repeated torture Electrical shock Sensory deprivation- loss of sense of time --solitary confinement --blindfolds

The professional work centered on the relief of the emotional suffering of clients automatically includes absorbing information that is about suffering. Often it includes absorbing that suffering as well. Dr. Charles Figley : 

The professional work centered on the relief of the emotional suffering of clients automatically includes absorbing information that is about suffering. Often it includes absorbing that suffering as well. Dr. Charles Figley

SELF CARE : 

SELF CARE Acknowledge stress Ask for help Don’t bring this stuff home! Exercise, meditate,pray Recognize the gift of doing this work: DON’T SWEAT THE SMALL STUFF!!

RECOMMENDED READING : 

RECOMMENDED READING Examining Asylum Seekers, PHR, August 2001 “Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (the “Isthanbul Protocol”) Testimonials, www.phrusa.org/compendium JAMA Human Rights Watch

CONTACTS : 

CONTACTS PHR Asylum Network, www.phrusa.org Samantha Morse, Asylum Networks Coordinator 617-695-0041 Bina Hanchinamani, Attorney, NWIRP, bina@nwirp.org, 206-587-4009 X 105 Rich Kovar MD, rkovar@cdchc.org; 206-299-1650 home-722-4989

You can look at a scar and see hurtor you can look at a scarand see healing. Sheri Reynolds : 

You can look at a scar and see hurtor you can look at a scarand see healing. Sheri Reynolds