Before arriving in Providence, Rhode Island, in 2007, former journalist Omar Bah was jailed and tortured in his home country of the Gambia for writing critically about the country’s dictatorship.

Bah’s harrowing experience of torture, and his later time spent as a refugee, inspired him to dedicate his career to researching trauma and resilience while supporting refugees through the Providence-based organization he founded called the Refugee Dream Center.

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“How does one who survives trauma emerge to become a leader, able to support fellow members of their community?” Bah asked, reflecting on his study of trauma survivors.

Bah was one of 20 faculty who taught this year’s 10-day Global Mental Health: Trauma and Recovery Certificate Program course at Harvard Medical School.

In a small study of 46 participants, Bah examined several factors that may explain how a leader who has suffered trauma manages to survive. These include physiological response to thinking about and narrating trauma, resilience, belonging, and experiencing a sense of well-being in life.

He used two experimental measurements to test stress response: a galvanic skin response device, which uses electrodes to measure changes in sweat gland activity, and heart rate variability, which has been used to detect stress levels.

His overall findings suggest that community leaders who have suffered trauma have stronger resilience, greater well-being, and healthy physiological responses when discussing their trauma.

The annual continuing education course Bah participated in trains health care practitioners throughout the world to apply human rights to their policy planning, clinical care, and humanitarian work.

For 13 of the 15 years the course has been offered, participants and faculty have gathered to learn in Orvieto, Italy. Last year’s course was cancelled, and this year’s was held entirely online.

Unprecedented global distress

Throughout the course, faculty presented research on the neuroscience of trauma, the global refugee crisis, racial trauma, World Health Organization policies that impact global health, and other areas related to global mental health.

The impact of COVID-19 on vulnerable communities and the health care teams that serve them was especially highlighted in this year’s program.

“The health practitioners and their staff, those who work with people who have suffered violence throughout the world: You are our treasure. Without this treasure, healing cannot occur,” said course director Richard Mollica, introducing the course on April 19.

“In this course, we’re not only providing you with a scientifically and culturally robust experience, but also nurturing and nourishment,” he said. “We all need this right now.”

Mollica is HMS professor of psychiatry and founder of the Harvard Program in Refugee Trauma (HPRT) at Massachusetts General Hospital.

In 1981, Mollica founded the program to offer clinical care, research, education, and advocacy for an exploding refugee population in the U.S., most of whom were asylum seekers. To date, the program has treated more than 10,000 survivors of torture and mass violence, he said.

The program has trained primary care physicians throughout the world to integrate mental health into their care. In 2006, Mollica and his team launched the Global Mental Health: Trauma and Recovery Certificate Program to develop global leaders in the field of mental health trauma and recovery and to offer a “scientific and culturally sensitive approach to healing the suffering from violence,” Mollica told this year’s more than 280 course participants who hailed from 38 countries.

Most participants work in the health care industry, including physicians, nurses, psychologists, social workers, and other public health professionals. But policy makers, lawyers, human rights advocates, educators, and journalists who work with survivors of violence or natural disasters also participated. The course format consisted of prerecorded videos followed by live Q and A sessions with faculty.

“In the 1980s, when I began my work at one of the first refugee clinics in the U.S., health care educators at Harvard and Yale had no concept of torture,” Mollica said. “We believed that people who lived through extreme violence couldn’t get better because they were too traumatized. We didn’t have any diagnostics or treatment interventions that could be adapted by other cultures.”

When Mollica visited the U.N. High Commissioner for Refugees (UNHCR) office during that time, he said the program staff claimed “refugees have no mental health issues.”

Mollica’s research, however, showed that indeed refugees had many unmet needs for mental health care. To date, more than 850 alumni of the program are working in 85 countries, practicing the HPRT model which includes assessment and diagnostic tools and interventions for healing from PTSD.

Global rights

Maria Leister, an attorney who presented a human rights lecture during the course, spoke of the core elements of human rights frameworks, which she referred to as the essential work that promotes the preservation of and restoration of rights for those who have lost them. These rights include direct care, data collection, advocacy, and education.

Leister shared her personal story of relying upon these frameworks as a young child who grew up in an orphanage.

“Like many children throughout history, at a very early age I was forced to rely on the conventional human rights’ frameworks and caretakers of human rights for my survival. Neglect from two sovereign nations, the U.S. and Korea, that left me stateless was the beginning of the systematic and structural process of stripping away my rights, my dignity, and ultimately pieces of my humanity,” she said. “These early events put me on a lifelong, rehumanizing journey—in other words, recovering the parts of my humanity that were systematically taken from me.”

Sondra Crosby, professor of medicine at Boston University School of Medicine, shared her analysis of the impact COVID-19 has had on vulnerable populations. She presented data on how the pandemic has led to increased risk for female mutilation throughout the world, saying it has exacerbated the risk of ill treatment and torture. She also said that because of the pandemic there has been limited independent monitoring and documentation of torture in prisons.

Interwoven throughout the course were diverse perspectives on mental health and cultural and racial disparities. Frederick “Jerry” Streets, associate professor of pastoral theology at Yale Divinity School, presented on racial trauma, highlighting the need for a racially informed and racist-free practice of mental health care.

Raewyn Mutch, clinical associate professor at the University of Western Australia School of Medicine, Dentistry, and Health Sciences, presented on the necessity of cultural competence in working with trauma in indigenous cultures.

Discussing a code of ethics in providing care, Mutch, said, “You listen to the community needs and how they’re addressed, and whether they need you or not. This is the same when you are working with traumatized youth; you need to be invited in and you need to listen to them.”

She also stressed that clinicians need to offer care with a “decolonizing” approach by integrating the values of indigenous communities into their practices.

Socioeconomic realities

Eugene Augusterfer, deputy director of the HPRT program, shared the program’s Global Mental Health Action Plan in a presentation with Taiwo Lateef Sheikh, national secretary at the West African College of Physicians in Nigeria.

Emphasizing the urgent need for a systematized mental health care plan and strategy to be adopted throughout the world, they presented data on the global costs of mental illness.

Annually, the cost is $2.5 trillion, they said, in both indirect and direct economic costs, a data point they believe underlines the need for policy makers to support mental health care, especially in countries with limited resources.

Their plan advocates for a global, systematic research agenda to generate studies and document findings on at-risk populations, promote community health services, and to study social determinants of health, health disparities, and racial trauma, empathy, and mindfulness.

In a second lecture, Augusterfer discussed the critical role of telemedicine in trauma recovery for populations impacted by war or natural disasters.

The HPRT model strongly emphasizes collaboration between primary and mental health care, which enables patients to accept mental health care more readily.

His research with Mollica and others examined the role of telemedicine for mental health services in post-disaster settings, finding that it is an effective tool for evidence-based care in low resource settings.​

In these settings, HPRT found that a combination of in-person and telehealth sessions were most impactful in serving the needs of these communities.

An empathetic approach

Throughout the course, one message was clear: Attention to human rights will not just improve the level of care clinicians provide but will also help pave a path for a safer, less-traumatized world.

“We live in an historic time where the enormity of problems such as the refugee crisis and human displacement, gender-based violence, ecocide, racial trauma, and the pandemic can be overwhelming to health care providers,” said Mollica.

“This course is based on the premise that out of tragedy comes hope, and that we are biologically wired to engage in empathy with others and with nature. We hope to inspire and support the next generation to devise innovative approaches to these challenges.”