Ross MacDonald, Zachary Rosner, Homer Venters
Since the United Nations Convention Against Torture was adopted in 1984, training physicians to care for survivors of torture has become a valuable addition to traditional medical education. Throughout the world, there are approximately 50 programs and clinics dedicated to caring for survivors of torture, with many more medical and mental health professionals caring for these patients in other settings. While the focus of this care may be on meeting the health needs of the individual patient, recording and reporting the outcomes of these patient encounters puts physicians in a critical role in addressing abuse.
In the New York City (NYC) jail system, health care falls under the purview of the Department of Health and Mental Hygiene’s Bureau of Correctional Health Services (CHS), while the NYC Department of Corrections is responsible for custody and security. The primary virtue of this arrangement is that the health service is run by an agency dedicated exclusively to promoting health, rather than health being provided under the direction of the Department of Corrections, as is the case in many other jail systems. CHS provides health care for approximately 11,000 patients at any time, spread across 12 jails and representing 75,000 annual admissions. In 2012, CHS leadership decided to formally integrate human rights into the overall health mission. Early human rights activities for CHS included training health staff on dual loyalty as well as making major modifications to the jail electronic health record to better monitor vulnerable groups of patients for injuries., The CHS health leadership includes three physicians trained in a local primary care residency that included dedicated education in evaluating survivors of torture. The residency-based program teaches the evaluation, assessment, and ongoing care of these patients. The physicians’ experiences during the residency provided a skill set that has helped us in caring for individual patients in the jail setting, as well as in formulating the policies and procedures around these encounters. (Figure 1)
Health and security policies dictate that health staff perform an injury evaluation on all patients who report injuries, are witnessed to be injured, or who are involved in a use of force with security staff. Approximately 1,500 of these injury encounters occur each month, with roughly 40% revealing physical evidence of injury. Our experience in caring for survivors of torture has improved our ability to care for injured patients in jail in several ways. First, it has helped us to think critically about potential discrepancies between accounts of injury and physical presentations. We have seen many patients with injuries characterized by high-energy trauma (including fractures of maxilla, mandible, humerus, cervical and thoracic spine, and perforation of the small intestine) who initially gave histories (or had staff-written accounts) of seemingly trivial incidents such as falls. Upon examination and discussion, these patients often relayed details more consistent with their injuries, often with subsequent corroboration by others during formal investigations. When we first published data regarding injury rates in the NYC jail system in 2012, the second-leading cause of injury was ‘slip and fall,’ representing 27% of all injuries. Our clinical experience is that many of these injuries stem from intentional, violent acts, but that patients feel intimidated to relate the true nature of their injuries. Through our dual-loyalty trainings, we have elicited feedback and provided guidance on these scenarios, including those in which security staff and patients disagree about the mechanism of injury. These observations have been important catalysts to discussions with security staff on methods to reduce injures, such as installation of surveillance cameras in key areas or elimination of solitary confinement for persons with serious mental illness.
The training has also been beneficial in bridging the worlds of clinical medicine, epidemiology, and human rights. Reporting on the rates of injury (and variables of individuals or the jail setting that are predictive of injury) would not occur with commitments to both human rights and epidemiology. For clinical staff, caring for injured patients can be demoralizing if their only role is to repeatedly care for patients who are injured (or cause injuries) without a role in reducing injury rates. In addition, just as patients may feel intimidation around reporting injuries, so too can staff. Thus, we have engaged staff in trainings around the issues of dual loyalty, and have also made major modifications to our electronic health record that serve to remove line staff from some high-pressure situations and instead, automatically report injuries, serious injuries, and injuries involving head trauma outside the clinic setting. Our intention with these measures is not only to improve care and reporting for injured patients, but to increase engagement with staff, so that they can be part of improving the system and feel supported to report their experiences.
Finally, the survivors of torture perspective has helped us to acknowledge and start to address high levels of secondary trauma among our health providers, who experience accumulated psychological stress from hearing and responding to the experiences of injured patients. Data from our dual-loyalty trainings and evaluations reveal that our staff are eager for more training, support, and guidance around how to process and reduce the stress of their daily work. In summary, we believe that our role as health leadership in a large jail system is greatly aided by having training and experience caring for survivors of torture. As academic institutions and public health agencies become increasingly involved in oversight of correctional health care, creating a systematic approach to training and evaluating health staff in these areas will improve patient care as well as general accountability. Although (or because) health staff assigned to specific facilities may face retaliation or resistance to engaging in this type of work, we believe that health leadership in jails and prisons should be trained and empowered to critically assess the burden and nature of injuries and the opportunities for risk reduction.
Figure 1. Survivors of torture training; applications in jail and the community
|Survivors of Torture Clinics||Correctional Physicians|
|Goals||-Document physical and mental health consequences
-Support immigration/asylum claim
|-Document physical and mental health consequences-Inform care-Ensure accountability|
|History Taking||-Extensive; covers both incidents involving torture and also those that did not but resulted in scars||-Limited, generally single incident relating to an injury|
|Physical Examination||-Head to toe; all scars as well as musculoskeletal system||-Brief, limited to injury site|
|Outputs||– Evaluation in medical records-Written affidavit-Testimony when needed||– Evaluation in medical records-Written report to investigatory authorities|
|Concerns/Management||-Training-Secondary trauma to staff caring for patients- Retaliation against persons reporting or documenting abuse||-Training
– Secondary trauma to staff caring for patients
-Confidential settings for examination often difficult to ensure
– Retaliation against persons reporting or documenting abuse
Ross MacDonald, MD, is the Medical Director of the Bureau of Correctional Health Services at the New York City Department of Health and Mental Hygiene.
Zachary Rosner, MD, is the Deputy Medical Director of the Bureau of Correctional Health Services at the New York City Department of Health and Mental Hygiene.
Homer Venters, MD, MS, is the Assistant Commissioner of the Bureau of Correctional Health Services at the New York City Department of Health and Mental Hygiene.
Please address correspondence to: c/o Homer Venters, 42-09 28th St, 10th floor, Queens, NY, 11101-4132. Email: firstname.lastname@example.org.
 MacDonald R, Parsons A, Venters HD. The triple aims of correctional health: patient safety, population health, and human rights. J Health Care Poor Underserved. 2013 Aug;24(3):1226-34.
 Glowa-Kollisch S, Andrade K, Stazesky R, Teixeira P, Kaba F, Macdonald R, Rosner Z, Selling D, Parsons A, Venters H. Data-Driven Human Rights: Using the Electronic Health Record to Promote Human Rights in Jail. Health and Human Rights 2014, 16/1.
 Kaba F, Lewis A, Glowa-Kollisch S, Hadler J, Lee D, Alper H, Selling D, MacDonald R, Solimo A, Parsons A, Venters H. Solitary confinement and risk of self-harm among jail inmates. Am J Public Health. 2014 Mar;104(3):442-7.
 Metalios EE1, Asgary RG, Cooperman N, Smith CL, Du E, Modali L, Sacajiu G. J Gen Intern Med. Teaching residents to work with torture survivors: experiences from the Bronx Human Rights Clinic. 2008 Jul;23(7):1038-42.
 Ludwig A, Parsons, A, Cohen, L, Venters H. Injury Surveillance in the NYC Jail System, Am J Public Health 2012 Jun;102(6).
 Kaba F, et al, Ibid.
 Glowa-Kollisch S, MacDonald R, Rosner Z, Venters H, Data-Driven Human Rights: Using Data from Dual Loyalty Trainings to Detect and Promote the Care of Vulnerable Patients in Jail. Health and Human Rights. In Press.