How doctors can help fix the broken US asylum system

Refugees fleeing persecution endure unimaginable hardships in search of a better life. Physician Joseph Shin explains the essential collaboration of doctors and lawyers working together to help asylum seekers in the United States, sharing promising pathways toward securing the human dignities they deserve.

Several years ago a young man
came to see me in my clinic.

He told me he was running for his life.

He said that he fled his home,

because there, homosexuality
wasn't just illegal,

in some cases it was punishable by death.

So when his sexual
orientation was exposed,

his family rejected him,

his boss fired him

and angry mobs repeatedly
attacked him in the streets.

And each time the police
arrived only to arrest him,

detain and torture him further.

And he knew that if he couldn't
escape the cycle of violence,

he would surely be killed.

So he had to do
what he needed to do to survive.

He left everything behind.

All of his friends,
his family, his career.

He fled his home,

he escaped to the United States

and here he applied for asylum.

But like many people
fleeing this kind of persecution,

he couldn't carry much.

He had some basic ID,

barely any money
and a few other belongings.

He certainly didn't bring
official documents

from the police who tortured him.

No videos from the mob
that tried to kill him.

He didn't have this kind of evidence
to help support his claims,

yet here he was, sitting in my clinic,

showing me some of the most powerful
evidence of his persecution.

That was the physical and psychological
scars that he brought with him.

You see, he suffered
from chronic, debilitating pain.

He had severe scars
scattered over his body,

poorly healing wounds
that got infected over and over again.

He suffered from severe depression

and continued to have regular, paralyzing
flashbacks and nightmares from PTSD.

So we continued our work.

We met regularly for months,

documenting each of these pieces
of medical evidence.

We went over the details of every attack,

photographed his scars,

documented his injuries and wounds,

and we were even able to start
chronicling his slow but steady recovery

while under our care.

Working closely with his lawyers,

I submitted a detailed affidavit,

including the findings
of this forensic medical evaluation,

and we included it as part
of his asylum application.

And then we waited

for several long years
while he navigated the courts.

And then one day I got an email from him.

It said that he was granted asylum.

And everyone in the clinic was overjoyed.

He said in his email
that this was the first time in years

that he didn't fear deportation and death.

It was the first time in years
that he truly felt safe,

that he had the security
to rebuild his life all over again.

And it was only through this medical
and legal advocacy

that we were able to help restore
his legal status and his rights,

that he could do that,

all through asylum.

Now for many people fleeing persecution,

they come to programs
and clinics like this

telling unimaginable tales of violence

and different reasons
they were persecuted.

But one thing is always the same.

The violence meted against them

was done with complete impunity,

sometimes by the hands of the state
directly through police

or military officials.

In other cases,
the state just turns a blind eye

and condones the acts
of paramilitary groups

or even violent domestic partners.

In other cases,
state is completely powerless

to protect the vulnerable
from powerful gangs.

Now we know that social determinants
of health play a huge role

in determining the health
and well-being of our patients:

housing, income, education, race,

social inclusion.

But the same can be true
for equal protection in the law --

due process.

Especially in societies
for the most vulnerable,

the marginalized

and even those who are actively targeted,

their access to these
human rights protections

that can mean the difference
between sickness and health,

and often it's the difference
between life and death.

And for millions of people
who endure persecution and torture,

the only way to heal

is to acknowledge the human rights
abuses that have occurred

and to help restore the rights
and protections that were so violated.

After the atrocities of World War II,

the asylum system was set up
as one pathway to that kind of relief.

But these days it seems like that pathway
has turned into an obstacle course,

setting people up to fail.

Asylum seekers oftentimes
don't know how to start,

let alone complete the process
that can drag on for years.

They're not entitled to lawyers,
so they don't know their rights.

Increasingly, they're even being barred

from setting foot
in places of potential refuge.

They're arrested or prosecuted,

even deported before they ever
get to see an asylum officer.

And even if they do
make it through the process,

asylum grant rates
can be as low as 20 percent

and far worse for some.

It's almost like the system was designed

to keep people
from exercising their right.

But there is something
that many of these people can do.

Something that can potentially
increase their chances of success

to 90 percent or more.

So what makes the difference?

Getting a lawyer
and having a medical evaluation.

It's as simple as that.

The man who came to my clinic
and won his asylum case.

Doctors and lawyers working together
to present all of the evidence,

including the medical evidence,

to the courts

allows judges to make
informed and just decisions.

And it's this kind
of medical-legal partnership

that's now more important than ever,

because we live in a time
of epic, forced migration

due to violence and conflict.

In 2018 there were 70 million
people worldwide forcibly displaced

due to war, conflict and persecution.

It includes 40 million
internally displaced,

25 million refugees
and three million asylum seekers.

Here in the United States,
we see the impact of escalating violence

in places like El Salvador,
Guatemala and Honduras,

where murder rates can be as high
as those in Syria and Afghanistan.

Where police corruption
and gang violence are on the rise,

where poverty and child abuse
are widespread and tolerated,

where basic systems of governance --

public safety,

child protection --

are ineffective.

It's no surprise then that many
of the most vulnerable

in some of these societies --

children, women
and other targeted groups --

they're growing increasingly desperate

and fleeing in unprecedented numbers.

Like over the past 10 years,

the numbers of unaccompanied children

trying to seek safety
at our southwest border

has increased 18-fold,

from 3,300 in 2009
to over 62,000 this past year.

That's in addition to nearly half
a million people traveling as families.

Men, women and children
trying to seek refuge at our borders,

but who are stranded
in a humanitarian crisis.

And what makes matters worse

is that they're caught in this fog
of claims and counterclaims

about who they are,

what they've experienced,

where the proof is

and what they deserve.

Do they deserve our help?

Sometimes people make claims

that they're not fleeing
human rights abuses

but are simply economic migrants.

Others say these children
are actually being exploited

and trafficked by their parents.

Others say they're
not even children at all;

they're hardened criminals,

they're gang members
trying to infiltrate our country.

To cut through some of this fog,

my colleagues and I conducted a study.

We looked at data
from children seeking asylum

who had medical evaluations.

And this is what the evidence told us.

80 percent of these children had evidence

of exposure to repeated physical violence:

assault and torture.

60 percent of the girls
and at least 10 percent of the boys

had evidence of repeated
exposure to sexual violence.

One young girl, telling a story

and having corroborating evidence

of being detained, beaten and raped
over the course of three years,

trafficked to other men

and even having the threats
of the murder of her entire family

if she should ever escape
or try to seek help.

90 percent of these children
had evidence of psychological harm

from indirect violence,

including such severe threats,

but also witnessing untold
atrocities with their very eyes.

One young boy described
the terror and the grief

and the utter fear

of seeing the mutilated bodies
and faces of his younger brother,

his aunt,

his uncle, his cousin,

all killed in a single gang attack
meant to send the community a message.

And of course the psychological
toll is immense.

19 percent of these children
had signs of anxiety disorder;

41 percent, depression

and 64 percent, PTSD.

21 percent also had signs
of suicidality as children.

To put this into some perspective,
returning combat veterans,

they have PTSD on the order
of 10 to 20 percent.

These children at three to six times
more likely to have PTSD

than a soldier returning from war.

Now despite this burden
and despite this trauma,

there are many others, still.

Children who come to seek safety
and enter into our immigration system

only to find further abuse

and even torture reminiscent
of the places that they fled.

You might remember
some of those headlines,

some of those images this past year.

Children being ripped
from the arms of their parents.

Toddlers, infants
in cold and unsanitary cages.

The absence of food, water
clothing and even soap.

There's also increasing reports
of medical negligence,

preventable complications,

child abuse,

sexual abuse

and even child deaths in US custody.

Sadly, many of these abuses
and crimes aren't new.

Some date back many years
and even across administrations.

But something's changed.

The scope and scale
of these abuses and crimes,

the systematic and seemingly purposeful
endangerment of asylum seekers

and also the impunity
with which it's being done

has raised the harm
to an entirely new level.

It reminds me of one
of the girls in the study

who told us how she pleaded
with one of her attackers,

asking him to stop,

asking why she was targeted.

And do you what his response was?

He says, "We can do this, because
there's no one here to protect you."

We can't let this be true

of children and other asylum seekers
trying to find help at our borders.

But what do we do?

As a physician,

I'm often dealing with difficult decisions

with some of my sickest
and most complex patients.

Of course we want to keep
our focus on their health,

their well-being, their quality of life,

but sometimes it requires
a deeper exploration of their values

to really understand how to move forward.

In a similar way,

our nation is facing a crisis

with the increasing number
of asylum seekers at our borders

and in our communities,

and it compels us to re-examine
some of our own fundamental values.

What does it mean
when we value health and safety?

What does it mean when we value security,

life, liberty,

the life of children?

What about this one --

what does it mean when we say
we value law and order?

Does that also include respecting
due process rights for an asylum seeker?

Now for some, when they hear these terms

they immediately gravitate
towards wanting to build more walls,

deploying more border patrol,

deporting more people

even if it means separating
children from their families,

subjecting them to psychological torture

or deporting them to places
where they might die.

All in the name of security.

All in our name.

But for me and for many others,

when I think of these values,

that pushes me
in an entirely new direction

and renews my commitment to try
to meet the needs of these asylum seekers

with every tool I have at my disposal.

So that when we say
that we value life and liberty,

we'll see these people
who have taken unimaginable risks

to flee imminent danger and harm

to try to find safety.

We'll meet them where they are

and provide food, water,
shelter, clothing.

And we'll certainly
meet them with medical care

and mental health care
that they so desperately need.

When we say that we value the rule of law,

and not just the privileges
it provides a few

but the responsibilities
it requires of all of us,

we'll make sure that we have
a functioning immigration system.

We'll make sure that we have
trained judges.

We'll make sure that we're not
settling for the illusion of law and order

that maybe a tall wall
or a militarized border might provide us.

We want the real thing.

We want judges to be able
to evaluate the evidence,

including the medical evidence,

and we want them to administer justice ...

fairly.

When we say that we value
health and well-being,

that we don't want to perpetuate harm,

then we'll deploy
trauma-informed strategies

at all levels of the immigration system.

It might start with retraining
border patrol agents

or immigration officials,

but it needs more medical,
mental health and child welfare experts

across the whole system.

And when we say that we value justice,

we won't let ourselves
be turned into the torturers

that many of these children
and other people fled.

We'll open up our detention
centers and our courts

to experts and advocates

to hold ourselves accountable.

And we may find that we need
to shut down most of them

and close these camps.

I believe that by working
in effective partnerships

with lawyers, doctors,
human rights advocates

and many others,

that we can work together
to meet these asylum seekers' needs,

that we can meet our historical,

humanitarian

and legal obligations to them.

And when we do,

I think something powerful will unfold.

Not only will these asylum seekers --

like the man who came to my clinic
and won his asylum case,

like the children in the study

or the many thousands of others
seeking a new life,

they'll be able to find
that safety and security.

We'll recognize the abuses
that have occurred,

and we'll restore the rights
and protections that were lost.

And I think that we'll be in wonder

when we see them in the fullness
of their humanity.

Not just their strengths and weaknesses,

their hopes and joys,

not just the trauma that we acknowledge,

but we'll also stand with them

and we'll be inspired by their resilience.

They'll blossom,

and they'll add
to the richness of this nation.

I think by staying true
to our fundamental values

in the way that I've described,

that's how we build a sane
and humane immigration system.

That's how we remain the golden door.

And that's how it happens

that we remain the shining
light of the world.

Thank you.

(Applause)