From War Zone to Contact Zone: Culture and Refugee Mental Health Services

Convention Relating to the Status of Refugees-as somebody who, "owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership in a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country." 1 Recent estimates suggest that there are approximately 50 million displaced persons worldwide, including internally displaced persons (who have not crossed international borders) and refugees. 2 Health care professionals engage with these populations in numerous ways, ranging from personal, clinical encounters with refugee patients to participation in international medical interventions.Good intentions and sound medical knowledge, however, are not sufficient to provide the health care required by this community of patients.With their history of displacement, persecution, fragmentation of cultural and familial structures, and violation of human rights, displaced persons have a more complicated biopsychosocial profile than most patients in the United States. 3 By becoming more aware of the various issues that affect members of displaced communities, health care providers may become better at confronting their acute and long-term health problems.Furthermore, the health care issues that apply to these populations may also apply to others who do not exactly fit the United Nations definition.Illegal residents or immigrants, those who have been internally displaced, and asylees who do not yet have official refugee status, for example, may benefit from the approaches and perspectives described for refugees.This issue of MS JAMA examines the special problems faced by refugees and displaced persons.Richard Mollica provides a model for how to incorporate the patient's trauma story into the primary care medical interview, so that this essential part of this story is not missed.Health care professionals must take into account the complicated perspectives of culture, human rights, and the ethical problems of international intervention.Stevan Weine proposes a more active engagement with the ramifications of culture in health care interventions, particularly as it pertains to the patient's family and local physicians.Alejandro Moreno and colleagues review the epidemiology of human rights violations in displaced populations and suggest how these might be addressed through the education of physicians and an awareness of human rights violations in the clinical encounter.Gina Jae interviews Philip Gourevitch, the author of We Wish to Inform You That Tomorrow We Will Be Killed With Our Families, a powerful and critical analysis of the genocide and refugee crises in Rwanda in 1994.Ferid Agani examines the mental health system of Kosova after the war and NATO interventions of 1999, focusing on the importance of recognizing local institutions in the rebuilding that goes on after such crises.