Racism in Medicine Innovation

Body of Rights

Delivering mental health support to refugees and their health care providers

Now more than ever, treating the mental health needs of the world’s more vulnerable populations means integrating human rights, trauma-informed care, and advocacy. For nearly four decades, this integrated approach has been fundamental to the work of the Harvard Program in Refugee Trauma (HPRT) at Massachusetts General Hospital. Founded by Richard F. Mollica, an HMS professor of psychiatry at Mass General, the program’s interdisciplinary team has developed methodologies for assessing and treating the mental health needs of refugees. It also has developed and translated training curricula for primary care physicians, mental health practitioners, and bicultural clinicians who grapple with providing care to patients whose mental health has been harmed by mass violence or natural disaster.

The tools HPRT has developed are now considered models of excellence in the field.

Today’s pain

The COVID-19 pandemic has brought a new urgency to the treatment of mental health trauma within the health care profession.

According to a report released in September by National Nurses United, a registered nurses’ union, more than 1,700 health care workers in this country have died from COVID-19. Although most agree that number is an underestimate, all acknowledge that the toll has been greatest among workers of color.

Compounding these losses is the racism that some health care workers are experiencing. This pandemic has seen a particular rise in racism toward Asian American health care workers, who represent more than 17 percent of physicians and nearly 10 percent of nurse practitioners in the United States. The racism and racial trauma revealed during the crisis were called out in an October 27 letter that appeared in The Lancet.

“The COVID-19 pandemic has not only revealed major health disparities in people of color … but also highlighted the often overlooked impact of racial trauma on health-care workers,” wrote Mollica and Dinali Fernando, an associate professor in the Department of Emergency Medicine at the Icahn School of Medicine at Mount Sinai.

“Racial trauma, similar to the refugee experience, is a human rights violation,” the authors continued. “Staff may need mental health counseling. We need to be cognizant that interns and residents in training might be especially vulnerable during this pandemic.”

According to psychiatrists Betty Pfefferbaum of the University of Oklahoma Health Sciences Center and Carol S. North of the Division of Trauma and Disaster at the University of Texas Southwestern Medical Center, it’s possible to draw parallels between the mental health disorders that may emerge following a mass tragedy and those arising from natural events such as a pandemic and to look for solutions in the best practices developed by disaster mental health professionals. In their August 6 Perspective in the New England Journal of Medicine, the authors wrote, “Medical conditions from natural causes such as life-threatening viral infection do not meet the current criteria for trauma required for a diagnosis of PTSD, but other psychopathology, such as depressive and anxiety disorders, may ensue.”

A need defined

While the topic of human rights moved into the public discourse with the United Nations’ 1948 Universal Declaration of Human Rights, it took several decades before the field of medicine, faced with waves of people fleeing war-torn and post-conflict societies and seeking asylum in this country, began to address the mental health conditions resulting from refugee trauma.

Years after his residency at Yale Medical School, Mollica developed a program that incorporated clinical care, research, education, and advocacy to serve the needs of an exploding refugee population in the United States, most of whom were asylum seekers. In 1981 he co-founded the HPRT, and since then, program staff have treated more than 10,000 survivors of torture and mass violence. They also trained hundreds of physicians who tended to those traumatized by the wars in Bosnia, Cambodia, Croatia, and Peru and who supported those who worked at Ground Zero following the 9/11 attacks.

Tread gently

Sometimes, innovation means finding solutions that simplify complexity. In assessing the mental health needs of refugees, open-ended interview questions can overwhelm or be culturally inappropriate. To remedy this, in 1993, Mollica drew upon the Hopkins Symptom Checklist to create the Harvard Trauma Questionnaire, which has since become the go-to tool for measuring the effects of torture, post-traumatic stress, and other adverse experiences on refugee health. It has been translated into thirty languages.

Applying decades of knowledge to a robust curriculum that would educate mental health professionals worldwide is the goal of HPRT’s Global Mental Health: Trauma and Recovery Certificate Program, an HMS course that is part of its continuing medical education offerings on psychology and mental health. Now in its fourteenth year, the certificate program has trained more than one thousand professionals who work in eighty-five countries.

The interdisciplinary faculty hail from backgrounds in medicine, psychology, and social work and come from both within and outside of Harvard. Maria Leister, an attorney who teaches topics related to human rights, justice, and equity, took part in the program in 2015. One year later, she was invited to join the faculty and now serves on the leadership team.

In last year’s on-site training in Orvieto, Italy, Leister spoke at length with program attendees seeking guidance and coaching on how to work within systems that fail large communities and populations. Employing an interdisciplinary approach that embraces the adoption of human rights both internationally and locally, she says, may open the door to a new model of caring for and empowering our most vulnerable populations. “We need to apply human rights aspirations and practices closer to home,” she says. “Because it’s not something that just the international community needs to implement. Our local and state communities also benefit from its careful implementation."

Lori Shridhare is a Boston-based writer.

Illustration: Mattias Paludi