The room is unassuming from the outside. It’s a tiny space not much larger than a storage closet tucked into an office in the school of public health. I do my usual clinic routine in reverse: notebook pulled out of pocket and white coat slipped off and left outside.
There is usually a shuffle of a few chairs as I enter. Our client is seated upon a small exam table while an interpreter and I take our seats on either side. At first, the only sound is of the physician scratching notes into a small notebook.
It is hard to predict who will be sitting on the exam table when the door opens. Young teens, grandparents, single mothers or families of ten: different people with widely different experiences from all corners of the earth end up in the same storage closet-sized room with the same desires to be alive, happy and free of persecution.
The United Nations High Commissioner for Refugees defines asylum-seekers as people who have left their homes to seek sanctuary in another country. Refugees, on the other hand, are people whose requests for asylum have been accepted and recognized by the country to which they have fled.
The process for gaining asylum is long and arduous, and most of the burden falls on the asylum-seekers. For asylum-seekers already living in the United States, they have one year to file an application for asylum that the United States Citizenship and Immigration Services can either grant or deny. Then, asylum-seekers are given a “credible fear interview” when they must explain the nature of their persecution in their home countries based on a protected characteristic in the United States like race or political opinion as well as their fears of harm should they return to their home countries.
If granted asylum, refugees gain a number of benefits. These include security to live without fear of being deported, work authorization, a chance for family reunion and eventual citizenship. Most importantly, as I’ve seen from my own experiences, an accepted asylum status is often viewed as recognition of the circumstances which led individuals to flee their home countries and can mark the beginning of a process of healing and growth.
Back in the tiny room, the physician starts introductions. “This is Zaynah, a second-year medical student. She works with a student-run clinic to coordinate a meeting with a medical professional to bolster your pending case for asylum in the United States. She will help verify the information we discuss and validate the documentation we will make of scars and injuries, both physical and psychological.”
Sometimes, the introductions are simpler. “This is Ms. Zaynah. She is here to help me.” Clients from some countries offer a hand to shake; others from more deferential cultures offer a slight nod from their seat on the exam table.
The interviews are the hardest part. The process is slow and circuitous. Patients recall some memories perfectly and vividly. Other details take time to remember as forgotten moments return piece by piece.
Most stories start many years in the past: People are not driven overnight to leave their homes and families. It takes years for a government to become corrupt or for gangs to begin targeting vulnerable individuals. Common threads appear, like minimal social support and limited access to medical care.
Knife wounds are clumsily sewn up in living rooms. Simple trips through town become harrowing and life-threatening. Often and ironically, individuals with the least involvement in the political machinations of their countries are nonetheless hurt the most. When the persecution becomes too much to bear, the citizens choose to leave everything behind and travel by whatever means necessary to the US to gain protections and start over as refugees.
During the “credible fear interview,” the physician is tasked with approaching each moment and detail with the scrutiny of a forensic detective. It is a challenging process for everyone involved. For example, if the physician is not meticulous with the details of the case, the resulting affidavit will lose its strength. Expecting an asylum-seeker to have all the details can feel unfair in itself.
The physical exam has the same forensic slant. Scars and past injuries are documented and measured, and details are cross-checked once more. More benign marks, like healed BCG immunization sites and old animal bites, are documented in the same way as proof of credibility. Point by point, event by event, and question by question, the physician circles around each point of clients’ stories until the physicians feel comfortable verifying asylum-seekers’ claims in a court of law. A finding such as a chemical burn is unmistakable. Others, like self-stitched wounds and nondescript scars, can be trickier to identify as signs of abuse. It is long but extremely valuable work.
Once physicians have all that they need, they write a legal affidavit to corroborate these findings in immigration court. A successful application for asylum does not guarantee acceptance. In 2017, only 38 percent of court asylum cases were approved. Approval rates vary widely depending on the specific immigration court, with some as high as eighty percent and others as low as ten percent.
It is a little-known fact that physicians and medical students stand to make a difference in the lives of asylum-seekers. In 2010, Physicians for Human Rights partnered with the Weill Cornell Center for Human Rights (WCCHR) to found the first student-run asylum clinic at a medical school. Since then, asylum clinics have formed across the country in unique partnerships with immigration lawyers, volunteer physicians and medical students working in unison to support a case for asylum in immigration court. A study done by the University of Michigan on the roles of physicians in asylum evaluations found that asylum seekers with medical affidavits bolstering their cases had an average of forty to fifty percent higher rates of acceptance compared to the national average.
For a medical student, asylum clinics provide an education unlike anything seen in a traditional hospital setting. Pre-clinical medical assistants stand to gain valuable hours of experience working with medical interpreters and navigating unconventional patient histories with understanding and compassion. Students are often involved in the affidavit-writing process and are privy to a unique intersection between medicine and law.
Especially in a refugee-dense area like my home in Atlanta, asylum evaluations provide rare glimpses into the stages of terror, determination and resiliency people must surpass before they are able to settle in the United States. I no longer overlook what it means when patients mention that they are refugees. To be a refugee is a sign of an incredible journey and indomitable strength in pursuit of a life well-deserved, and I will always be honored to serve such incredible populations in my medical practice.
Writer-in-Training
Emory University School of Medicine
Zaynah Alam is a member of the Class of 2021 at Emory University School of Medicine. She grew up in Chapel Hill, NC and has a BS in Neuroscience from Duke University. Her interests include science fiction, health as a human right, and eating at every pho restaurant in the city of Atlanta.