Libertas Medical Director Dr. Dinali Fernando, the 2018 Pearl Birnbaum Hurwitz Humanism in Healthcare Award winner, has led the center from a volunteer program to a comprehensive, torture-survivor treatment center that advocates nationally for this underserved, hidden population.
Not long ago, a man arrived at the Emergency Department at Elmhurst Hospital in Queens, New York, complaining of terrible gastrointestinal pain.
One of the emergency medicine physicians, Dr. Dinali Fernando, learned that he had been placed in detention upon arrival in the United States and was seeking asylum here. She gave him a brochure about the Libertas Center for Human Rights at Elmhurst Hospital, where she is the Medical Director, and explained what specialized support was available. The Libertas Center offers comprehensive medical, mental health, social, and legal services for immigrants who have suffered torture and human rights violations in their home countries.
Dr. Fernando, who is also an assistant professor at the Icahn School of Medicine at Mount Sinai, suspected that there was a complex host of factors contributing to the patient’s symptomatology. When she cared for him a second time during a repeat visit to the ED, she gently encouraged him again to seek care at the Libertas Center.
And he did.
Jacqueline Chiofalo, former Libertas Program Assistant, remembers first meeting him when he walked into the Libertas Center. “We needed to do an intake, but he was grimacing in pain,” she recalls.
Libertas Clinical Case Manager Elizabeth McInnes started working with him, and he began to talk through his traumatic past.
“Once he started talking about his problems and receiving mental health care, his symptoms really started to subside,” says Ms. McInnes.
“Ultimately, it ended up [that his pain was a] symptom related to PTSD and the trauma he had endured,” says Ms. McInnes. He has since received individual therapy and medication management. Today, he is doing better. He has health insurance, and he’s working, says Libertas Program Director Matthew Kennis.
“We’re really glad he came to Libertas” says Dr. Fernando.
This patient is one of hundreds of torture survivors who have been cared for by the Libertas Center for Human Rights. Under the leadership of Dr. Fernando, who has served as the Medical Director since 2009, the Libertas Center has grown from a pro bono program to a grant-funded, comprehensive torture survivor treatment center with six core staff members and a mission to help clients heal and rebuild their lives.
The center offers medical, mental health, legal and social services, as well as complementary treatment modalities, such as art therapy, that encourage clients to express themselves and find their voices again. The staff advocates locally and nationally for a wider awareness of the needs of torture survivors and improved policies and services to address those needs.
Dr. Fernando’s work has been galvanizing and groundbreaking. When she first joined the Libertas effort in 2006, as a volunteer resident physician, the program was entirely run by volunteers with no designated funding or offices.
“Dinali is the through line…of the program, which has sustained it and provided leadership as it has grown and evolved over time,” emphasizes Mr. Kennis.
In recognition of Dr. Fernando’s impact, The Arnold P. Gold Foundation will present her with the 2018 Pearl Birnbaum Hurwitz Humanism in Healthcare Award this fall.
The immense number of torture survivors
About 1.3 million survivors of torture are estimated to be living in the United States, among the resettled refugee population – this does not count the approximately 260,000 additional survivors who have been granted asylum within the United States in the past couple of decades, says Mr. Kennis.
New York City is home to an outsized portion of torture survivors. An analysis of pending and granted affirmative and defensive asylum applications and Convention Against Torture case completions in the New York Immigration courts suggests that at least 133,000 individuals sought humanitarian relief in the immediate New York City area in recent years. This estimate does not include survivors who remain undocumented, who were granted relief before fiscal year 2016, or who moved to New York City after being granted humanitarian relief elsewhere.
Asylum seekers are not afforded access to services and typically have little or no support, says Dr. Fernando. This vulnerable population is often overlooked. In a study published in Academic Emergency Medicine, Dr. Fernando and colleagues did a cross sectional survey of Emergency Department (ED) patients in Elmhurst Hospital in an effort to estimate the prevalence of torture survivors presenting to their ED, often the portal of entry into the health care system for these clients.
The study estimated that 6.2% of patients who present to the Emergency Department are survivors of torture — at the Elmhurst Hospital ED, which sees some 90,000 patients annually, that translates to several thousand torture survivors walking through their doors each year. Most doctors are not formally trained in how to identify a torture survivor, let alone the particular needs of such a population. Not surprisingly, about 78% of those who self-reported as torture survivors in the study said no doctor had ever inquired about their torture history, highlighting the need for provider training.
All of this makes the Libertas Center a unique place of care.
Who the Libertas Center serves
At any given time, the Libertas Center actively serves approximately 150 clients. About half of the clients are female and half are male, they are largely Christian or Muslim, and they hail from over 60 countries around the world.
The majority are adults, ages 25 to 44. More than 80% have experienced threats or psychological torture, more than 60% have experienced beatings, more than 40% have been wounded or maimed, and about 30% have experienced rape/sexual violence, with many clients having experienced multiple forms of torture.
The Libertas Center works with clients to identify and address their needs – social, legal, mental health and medical.
While the array of services today is comprehensive, the Libertas effort first began more than a decade ago with the simple and critical need for forensic evaluations.
A forensic evaluation entails obtaining a client’s torture history and evaluating for physical scars consistent with and mental health symptoms resulting from the torture. The findings are written in an affidavit that can be submitted with a client’s asylum application.
These clinical evaluations are a critical component of a person’s application for asylum in the United States, and few doctors are formally trained to conduct them. Without a forensic evaluation, the average grant rate for an asylum case is only about 40%, explains Mr. Kennis. That grant rate increases to over 85% with a forensic evaluation.
Approximately 87% of Libertas Center clients identify as asylum seekers, and to date, more than 95% of clients who have received a forensic evaluation provided by the Libertas Center have experienced a positive outcome in their immigration cases.
The Libertas Center’s early years
It was this crucial need for forensic evaluations that sparked the initial Libertas effort.
In 2006, two emergency medicine physicians at Elmhurst Hospital, Dr. Lars Beattie and Dr. Rajeev Bais, began offering pro bono forensic evaluations to survivors of torture. Dr. Fernando was then a resident physician at Mount Sinai with a passionate interest in caring for this population. As a medical student, she had been introduced to caring for torture survivors during her psychiatry rotation at the Northern Virginia Family Service Program for Survivors of Torture and Trauma.
“That was really life changing for me,” Dr. Fernando recalls of her time at the Northern Virginia program. “The very first torture survivor I worked with as a student was catatonic. She would not speak one word. I just remember being in the room and thinking, how am I going to evaluate her because she’s not speaking at all? It was really powerful, and my first exposure to this work.”
Dr. Fernando sought out Mount Sinai for her residency in particular because of its affiliate trauma center, Elmhurst Hospital in Queens: “Elmhurst is in one of the most diverse neighborhoods in the country [and] Elmhurst Hospital is a safety net hospital. It was exactly the type of setting and the population I wanted to work with, so I was very excited to do my residency here.”
Once at Elmhurst Hospital, Dr. Fernando joined the volunteer efforts of Drs. Beattie and Bais to identify torture survivors and offer pro bono forensic clinical evaluations. The group began looking for funding, and in 2009, the first grant was awarded. Dr. Bais had moved on to India, and Dr. Beattie had to move to Florida, leaving the newly funded endeavor in Dr. Fernando’s hands. She took over the Libertas Center for Human Rights as Medical Director in 2009 and hired the first staff member.
It had been challenging to find space in a busy Emergency Department for such examinations, which need to be done in a private room. Once funding came through, Dr. Fernando began working with Elmhurst Hospital to secure dedicated space within the hospital. Over the years, they’ve expanded from two rooms, to three, and now to five.
“Right now, we expand our space, and we’re immediately at capacity because there are so many clients in need of our services” says Mr. Kennis, explaining that the program is successfully identifying those in this hidden population who need help. Dr. Fernando and her staff are very grateful to both Elmhurst and Mount Sinai Hospitals, which continue to champion the Libertas Center’s work via generous in-kind support.
Learning about their clients’ needs
Funding has helped to expand the Libertas Center’s services and staff, as well as support education and research that helps providers to better understand what clients need and how services are best delivered and used.
When new clients arrive, a staff member leads them through an intake process to learn about their needs and wellness goals.
“We really want to hear them out and empower them to prioritize their treatment goals, rather than what we might think they need,” says Dr. Fernando.
About 47% of Libertas clients indicate that mental health is their primary need; 29% report a primary medical need; and 22% indicate a primary legal need. The comprehensive care model of the Libertas Center allows for many check-ins along the period of treatment, so that emerging needs can be addressed as they are identified. Although rarely self-identified as a primary need, over 95% of clients identify secondary social service needs and 99% of clients utilize social services.
Research on utilization of services by Libertas clients has shown that clients who didn’t report needs in certain service areas often end up using those services later. For example, in a study of 219 Libertas clients who used medical services between 2010 and 2016, 45% of clients who did not report medical needs at intake still utilized medical services. Similarly, in a study of 141 Libertas clients between 2013 and 2017, 70% of clients utilized psychosocial support although it was the least requested social service at intake, with only 24% of clients requesting it.
Ms. McInnes explained that clients may not be able to articulate their full needs at the initial intake meeting. “Clients oftentimes come in and say, ‘I feel crazy, I’m crazy,” she said. “Then we go through this process of helping them understand that their symptoms are a result of their torture and their trauma, how their symptoms have impacted them, and it’s not that they are crazy. Our therapist Walter always says, ‘You aren’t crazy. What happened to you is crazy.’ We empower them to realize that they can work on and address these symptoms, and that can be a process, but also a transformation for them to feel more power and agency in their treatment.”
The impact of the Libertas Center
“Before reaching the door of the Libertas Center, we were totally helpless in finding the mental and emotional health support we needed. I never imagined that people like me who were depressed and persecuted at home could have a renewed life with hope and aspiration.”
— Libertas Client, 2016
As Libertas Center clients receive care and services specifically designed for their particular needs, they begin to settle into a better place. The staff follows up 6, 12, and 18 months after a client’s initial intake meeting to address new and ongoing needs.
After receiving services at the Libertas Center, clients report improved outcomes.
More clients are employed and have work permits at follow-up (70%) than at the initial Libertas intake meeting (40%).
Advocating for policy change
Dr. Fernando and the Libertas Center staff also serve as advocates for torture survivors and help raise awareness of their needs to policymakers and government leaders at the city, state and national levels.
One obstacle is a frequent misunderstanding of who asylum seekers are. Unlike immigrants who might want to enter the United States for better economic opportunities, those seeking asylum are fleeing for their lives. They have been tortured in their home countries by someone in a position of power, often for reasons such as political opinion, race, religion, gender, sexual orientation, or social activism. They arrive in the United States without connections or support and are seeking humanitarian relief.
About half of Libertas clients are college educated, and many speak multiple languages. “We’re really trying to bring to light that these clients are very successful, bright, passionate individuals who were often advocates and leaders in their own communities, which is why they were persecuted in the first place. If given the opportunity, they can give back so much to our community,” says Dr. Fernando.
“The Libertas Center opened a window of opportunity and hope. Now I have my green card and am working as a lead teacher in a school in NYC. I want to settle down with my daughters and assist them to follow my pathway to a successful life; I want to show my daughters how to be strong and fight for their rights.”
— Libertas Client, 2015
The goals of the Libertas Center include continuing to expand the number of clients they serve, widen awareness of the needs of torture survivors, at both the provider and policy maker level, enhance provider training, and strengthen research on best practices in caring for torture survivors so that this specific kind of holistic care can be available to all survivors across New York City and beyond.
Dr. Fernando looks forward to establishing a human rights fellowship in the future to give physicians specific tools and training to care for those who have suffered torture and human rights violations.
“It is hard work. Nobody would ever say it’s easy work,” says Ms. Chiofalo, who first came to the Libertas Center as a college intern in 2012 and returned after graduation as a full staff member. “What really makes a difference is when you have strong mentors to teach you and keep you going and remind you what’s important. And I really think Dinali embodies all of that.”
Dr. Fernando will be presented the 2018 Pearl Birnbaum Hurwitz Humanism in Healthcare Award on October 10 in Boston at the Planetree International Conference on Patient-Centered Care. Learn more about the award and the conference.