PROPOSAL: Health care must be comprehensive, in that it must include multidisciplinary treatment. It must include a multidisciplinary program for psychosocial rehabilitation. It must include social and legal guarantees in order to protect rights and interests. It must include prevention of political violence. It must include education on and preparedness for torture, encouraging strong commitment to a cause. It must include immunization against traumatic stress as a result of thorough debriefing upon any happenstance exposure. It must include strong social supports and social initiatives. It must help heal victims of human rights violations, which requires avoiding retraumatization and helping the victim reintegrate into society as quickly as possible. It must substantially provide these resources to victims within one week of the traumatic injury. Any Health Care policy must include all of the above.
BACKGROUND: "Torture has reached an epidemic proportion throughout the globe. ... Increasing awareness of professional obligation for prevention of torture will play a definite role in promoting a peaceful world."(1) "Growing recognition that the world faces a modern epidemic of torture..."(2) has redefined health care, adding a political dimension.(3) "Those exposed to political violence reported more chronic pain and role limitations due to physical problems, as well as worse physical functioning and lower perceptions of general health than those who were not exposed to political violence."(4)
"The shocking, unfiltered images from the Abu Ghraib prison in Iraq have focused the world's attention on the plight of torture survivors. Physicians in the United States are confronted as never before with the need to identify and treat the physical and psychological sequelae of extreme violence and torture."(5) "In spite of the treatment, emotional distress seems to be chronic for the majority of this population."(6)
"Torture survivors comprise the most vulnerable group in the society after the war and they require multidisciplinary program for their psychosocial rehabilitation. This, comprehensive approach includes social and legal guarantees in order to protect their rights and interests."(7) Therefore, "preserving human rights and healing the victims of human rights violations"(8) are key health care goals.(9)
"Prior knowledge of and preparedness for torture, strong commitment to a cause, immunization against traumatic stress as a result of repeated exposure, and strong social supports appear to have protective value against PTSD in survivors of torture."(10) "Further, there is evidence to support the hypothesis that social support does moderate females' responses to certain types of strain."(11)
"Neurological sequelae of torture can be devastating physically and psychologically. The treatment of these neurological conditions does not differ from other patient populations. However, the clinical approach is unique and must focus on avoiding retraumatization and helping the victim reintegrate into society as quickly as possible."(12) "Both administrative and clinical decisions often must take into account political realities not found in other treatment environments. To overcome these obstacles has required building an agency with a small economy, a sense of community among its workers, flexibility about the presence and pervasiveness of politics, the ability to address countertransference, and goals that allow workers to cope with the difficulty and size of the problem of torture."(13) "Different interventions may be needed for three components of survivors' traumatic experience: cognitive and behavioral strategies for treatment of PTSD symptoms, marital or family strategies for minimizing the impact of the trauma on the family, and strategies for enhancing social support to minimize postcaptivity depression and anxiety."(14)
"The prognosis depends on a number of issues pertaining to the patient, the trauma, and the patient's overall state after the trauma. At best, the prognosis is relatively good, but in a number of cases the patient's state becomes chronic and disabling. At present, the recommended treatment is a combination of psychotherapy, psychopharmacological treatment, physiotherapy, and social initiatives."(15)
REFERENCES:
1. J Indian Med Assoc. 2000 Jun;98(6):320-6. Torture and mental health. Chowdhury AN. Department of Psychiatry, Institute of Postgraduate Medical Education & Research, Calcutta.
2. Aust N Z J Psychiatry. 1991 Dec;25(4):481-90 Psychosocial needs of torture survivors. Silove D, Tarn R, Bowles R, Reid J. School of Psychiatry, University of NSW, Liverpool Hospital, Sydney.
3. Health care for refugees and survivors of torture is becoming a growth industry, experts sadly say. JAMA. 1995 Jul 26;274(4):288-90. Skolnick AA.
4. JAMA. 2003 Aug 6;290(5):627-34. Mental health and health-related quality of life among adult Latino primary care patients living in the United States with previous exposure to political violence. Eisenman DP, Gelberg L, Liu H, Shapiro MF.
5. Surviving torture. Mollica RF. N Engl J Med. 2004 Jul 1;351(1):5-7.
6. J Nerv Ment Dis. 2005 Oct;193(10):651-7. A follow-up study of mental health and health-related quality of life in tortured refugees in multidisciplinary treatment. Carlsson JM, Mortensen EL, Kastrup M.
7. Med Arh. 2003;57(2):105-8. Torture as a medico-psychological and social problem. Kucukalic A, Bravo-Mehmedbasic A, Masic I. Psihijatrijska klinika KCU Sarajevo.
8. Issues Ment Health Nurs. 1992 Oct-Dec;13(4):311-20 Part II: The treatment of torture survivors: a review of the literature. Laurence R. ("Various treatment modalities have been proposed for working with survivors of torture. In this article, treatment aimed at both the individual and community is discussed. The role of nurses in preserving human rights and healing the victims of human rights' violations is also outlined.")
9. "In 1974, a young woman was arrested and tortured in Calcutta, India. ... A review of the case indicates the need for great strength to survive torture without the loss of will to bring the case to justice." Dan Med Bull. 1988 Oct;35(5):493-5. Why are torturers never punished? Vesti P. International Rehabilitation and Research Centre for Torture Victims (RCT), Copenhagen, Denmark.
10. Am J Psychiatry. 1994 Jan;151(1):76-81 Psychological effects of torture: a comparison of tortured with nontortured political activists in Turkey. Basoglu M, Paker M, Paker O, Ozmen E, Marks I, Incesu C, Sahin D, Sarimurat N. Institute of Psychiatry, London, England.
11. Sociological Inquiry 74 (4), 546-569. Revisiting the Moderating Effect of Social Support on Strain: A Gendered Test. Monica L. P. Robbers (2004)
12. Spinal Cord. 2002 May;40(5):213-23 Torture and its neurological sequelae. Moreno A, Grodin MA. Boston University School of Public Health, 715 Albany Street, MA 02118-2526, USA.
13. J Ambul Care Manage. 1998 Apr;21(2):39-42; discussion 43-55. Treatment of survivors of political torture: administrative and clinical issues. Gray G. Survivors International, San Francisco, CA, USA.
14. Factors related to long-term traumatic stress responses in survivors of torture in Turkey M. Basoglu, M. Paker, E. Ozmen, O. Tasdemir and D. Sahin Institute of Psychiatry, University of London, England.
15. [Reactions to torture and persecution. Traumatized refugees in the Danish health service] Norregaard C. Voksenpsykiatrisk afdeling V, Psykiatrisk Hospital i Hillerod.