Refugees, 2013: Changing faces, changing places, changing policies

This week’s Economist has a fine summary of how refugees have grown in number and diversity, and the international community’s response to these changes. Among things to note is the continuing trend observed a few years ago in a JAMA commentary (and critiqued by a skeptic or two… oops) of urban resettlement, which UNHCR now says it prefers to people resettling in refugee camps. UNHCR is also more explicit about its policy encouraging local political integration and even economic development as solutions in long-term refugee crises. These efforts are mirrored by changes in policies of countries who receive the most refugees (overwhelmingly in the developing world).

David Apollo Kazungu, Uganda’s Commissioner for Refugees, says it no longer makes sense to treat refugees as a humanitarian issue. “Those who stay for years throw up developmental problems for us, such as how to find enough land, water and jobs for everyone,” he argues. Uganda has already tried to improve the lot for the nearly 200,000 refugees it hosts by placing them in settlements rather than camps, and by giving them land to farm.

Within this discussion is the acknowledgement that forced migration and voluntary (or economic) migration are not entirely separate phenomena. Read the entire article here.

Recent focus on child soldiers and what the research says

The International Criminal Court (ICC) has made its first ruling, convicting Congolese rebel leader Thomas Lubanga of using children younger than 15 as soldiers. For basic media coverage, see here, here, and here. The conviction if Lubanga is the ICC’s first in its decade of existence, and for those of you interested, the BBC has a decent discussion of the costs, estimated at $900 million, here.

Lubanga could have been accused of any number of war crimes, but the ICC chose to focus on child soldiering (due to the quality of evidence, say prosecutors). The recent Invisible Children anti-Joseph Kony video recently trending on Twitter (no need for a link, I’m sure) chooses to also focus on child soldiering. Clearly this is compelling stuff for the media as well as legal teams, nightmare material for those who love kids and those who fear teenagers. From the sympathetic side we often hear simplistic pronouncements like this one from today’s New York Times:

Social workers say that even if children have enlisted willingly, looking for food, status or protection, they are often still permanently damaged by war-time violence and drugs.

There is, however, a research literature on child soldiers that presents a more nuanced picture. Although certainly former child soldiers suffer higher rates of physical and mental health problems than similar kids, the research suggests that there is more hope for them than is commonly portrayed. The work of Jeannie Annan and Chris Blattman show that there is wide variability in what child soldiering actually entails, and, that former child soldiers – far from being permanently damaged – are more active in peaceful post-conflict political processes than their peers. Theresa Betancourt‘s work shows that symptoms of emotional distress decrease over time among many, and I believe she has plans underway for treatment trials for those with continuing problems. Brandon Kohrt’s work presents (among other things) complex stories of reintegration through film, as well as research articles.

All this is not to say that child soldiering is in some way really not so bad. Making this a cause is indeed appropriate. But there is more to the issue than just crazed violent teenagers and their adult bad guy overlords. Child soldiers become former child soldiers, adults who live lives and can contribute to their societies.

Supreme Court hears Somali refugee’s case against the Somali refugee who tortured him

The United States Supreme Court is hearing a torture case today, but not one involving Guantanamo, Abu Ghraib, or Bagram. NPR’s Morning Edition reported this morning on the case of Bashe Yousuf, a Somali refugee living in the US suing a former leader of Somalia, Mohammed Ali Samanatar, who is also a Somali refugee living in the US.

The lead plaintiff is Bashe Yousuf, a Somali businessman who was doing volunteer work to clean up hospitals in 1983 when he and fellow volunteers were arrested. He was tortured for several months — subjected to electric shocks, trussed up and hung for hours, and waterboarded. And then he was held in solitary confinement for six years. In 1989, he was finally released and granted asylum in the United States, where he is now a citizen.

Transcript and link to audio here.

The case in front of the Justices pits the Torture Victim Protection Act against the Foreign Sovereign Immunities Act. The conflict, back and forth in Federal courts in Virginia, is essentially over foreign dignitaries can be sued in the US for torturing their own citizens. Although both plaintiff and defendant are both now in the US, at the time of the torture they were not, and so this case wades into the rather sticky legal territory of applying US law to things that happened in other countries.

Although this is clearly not an “enhanced interrogation” case, Mr. Yousuf’s case strikes a particular chord these days, in ways that cases previous to the revelations at Abu Ghraib (e.g., the case of an Ethiopian refugee suing her past torturer a few years ago) did not.

He is suing Samantar, he says, not because he fears for his safety anymore, but to make the man answer for his crimes.

“It’s outraging me,” he says, “that somebody like him can live in America.”

Cambodia 2009: Khmer Rouge and expelling asylum seekers… for a price

2009 will be remembered in Cambodia as the year of the first Khmer Rouge Tribunal. Duch (born Kang Kek Lew), head of the torture center S-21 during the Khmer Rouge was put on trial, causing considerable consternation for some, and some small measure of consolation for many who lived through that era (1975-79). This soul-searching, however, seems to have had little effect on the Cambodian government, as was recently shown by Cambodia’s expulsion of Uighur asylum seekers in exchange for foreign investment from China. (More background here.) Twenty Uighurs had sought asylum in Cambodia following China’s crackdown following the unrest in western China this past July. For those of you who don’t know, the Uighurs are a Turkic Muslim minority in China, and have in the past few years resisted aspects of Beijing’s development strategy of the Xinjiang Uighur Autnomous Region (which, of course, is not really autonomous), involving encouraging Han Chinese from the East to “go west.” Incidently, Xiinjiang’s Governor, the architect of the repression of protests this summer, had a similar job before this one: head of the Tibetan Autonomous Region.

Why did the Uighurs go to Cambodia? If you look on a map of Asia, it’d be hard from them to go farther and remain on the mainland. Well, Cambodia is one of only a very few countries in the region to have signed UN Convention Relating to the Status of Refugees. The others in East Asia are Japan, South Korea, the Philippines, and… China. (Central Asia has a few signatories, though I might think twice before applying for asylum in Kazakhstan; South Asia, surprisingly to me, has none.) During the Khmer Rouge millions fled Cambodia to neighboring states as refugees (neighboring states that were not particularly welcoming), and many sought asylum around the world. So it makes sense that if any country in the Asia were going to be sensitive to the needs of refugees and asylum seekers it would be Cambodia. And there are, therefore, asylum seekers from around the world who have successfully sought asylum in Cambodia.

But China is the biggest investor in Cambodia, and therefore has a voice in Cambodian affairs. The Chinese are calling the twenty Uighurs criminals (of course, in a country that doesn’t allow protest, protestors are criminals), so Cambodia calls them “illegal aliens,” and expels them. Two days after the expulsion, Cambodia signed a deal with China for $850 million.

Add mock execution and death threats to CIA tactics, and call them torture

Legal guidance provided for in 18 U.S.C. 2340(1) — that’s a bill from US Congress — clearly lists death threats as a form of inflicting “severe… mental suffering,” which is the key to determining whether an act constitutes torture or not. This week Newsweek reported that the CIA threatened the terrorist suspected in the bombing of the USS Cole with a gun and a power drill. In addition, the CIA staged a mock execution in the room next door to the interrogation.

Why should we consider death threats and mock execution as torture? If we consider Basoglu’s research (see June 23, 2009 entry of this blog) that shows that the psychological effects of torture are more impactful than the physical assault (i.e., produce the psychopathological reactions), we can see that death threats made in settings in which their “success” is likely (i.e., whether they have a high perceived probability of actually being fulfilled) are quintessential torture experiences. The context of powerlessness in the face of extreme pain or death is the determining factor.

The Khmer Rouge Tribunals and PTSD: Human rights law as mental health intervention?

Jeff Sonis (University of North Carolina at Chapel Hill) has published an important paper in the August 5 edition of the Journal of the American Medical Association that has interesting implications for the intersection of human rights and psychology, and for the effects of the Khmer Rouge Tribunals in particular. Using an impressive multistage sampling method, Sonis and a group of Cambodian, Dutch, and South African colleagues recruited a probability-based sample of 1017 Cambodians (the most impressive such sample in Cambodia to date), and asked them about their knowledge and expectations about the Khmer Rouge Tribunals, their desire for revenge on the perpetrators, and administered a measure of posttraumatic stress disorder (PTSD) and mental and physical disability. In order to account for the fact that the majority of Cambodians were not alive during the “Pol Pot time” (1975-1979), they oversampled those older than 35 years old (meaning they increased the proportion of this group in relation to the general population) in order to make sure they could examine how those people who were the direct victims of the Khmer Rouge felt about the tribunals.

Why do this? This is the baseline study of research in which Sonis and colleagues will examine the effects of having the tribunal on Cambodians mental health. Building on therapeutic approaches like Testimony Therapy (developed by Chilean psychologists in the Pinochet era) and really catching fire around the time of South Africa’s Truth and Reconciliation Commission, the idea that human rights tribunals could have direct salutory mental health effects has been very attractive to trauma psychologists. This is in line with the now very popular idea of therapeutic jurisprudence, in which the court’s actions are designed to “treat” the victim of a crime (unfortunately used in the US primarily to justify harsher punishments on perpetrators). Of course, there is the possibility that testimony may bring up painful memories which will cause further distress. Sonis explains it this way in the introduction:

Since anger and desire for revenge have been shown to be associated with PTSD symptoms and functional disability, tribunals might reduce the prevalence and severity of PTSD and impairment in postconflict societies by facilitating feelings of justice and reducing the desire for revenge. However, others have suggested that trials may actually increase PTSD prevalence and severity by “retraumatizing” survivors. (p. 528)

With the type of information they collected and the fact that it was all collected before the tribunals began, Sonis and colleagues can’t really answer the question of whether or not the tribunals were therapeutic (nor would they say they could). So what did they find? Well, the first notable finding was the prevalence rate among the over 35 group (the people present during the time of the Khmer Rouge). Within this group the rate of “probable PTSD” (“probable” because the self report measure is not technically diagnostic) was 14.2%. I usually don’t get excited about epidemiology, but let’s put this finding in context: Of the great killers of the 20th century — Hitler, Stalin, Mao — none were responsible for killing 20% of a population. That award goes to Pol Pot. This is in addition to the slave labor camps and torture chambers that were a part of everyday life under the Khmer Rouge. The fact that among those who survived this era, 14.2% suffer from PTSD is, to me anyway, a pretty optimistic finding. Granted, it’s 35 years later (a lot of PTSD may have been present for a long time and then remitted), but still, the common perception that Cambodians of that age are a traumatized population is simply not true, if you take the definition of “traumatized” as “most have PTSD.” That’s not to say that a higher proportion of Cambodians are affected by PTSD than members of other societies, only that a sizeable majority are not. People, even those who have gone through unspeakable terror, turn out to be pretty resilient. The population rate for PTSD was 11.2% (that’s for both groups combined).

What else? The expectation that the tribunals would deliver justice was inversely associated with probable PTSD. Sonis and colleagues conclude that this means that this “raises the possibility that the trials may be an effective societal-level intervention for reducing PTSD symptoms” (p. 535). However, the authors also found that almost 93% of those who knew about the trials reported that the prosecutions would probably bring up painful memories, and that raises “the possibility that the trials could increase the prevalence and severity of symptoms of PTSD” (p. 536). Hm. This confirms that both arguments made at the beginning of the study might hold water, but doesn’t really say anything more. Sonis ends with a rare instance of foreshadowing in academic writing: “That question can only be answered through a longitudinal study over the course of the trials” (p. 536).

I’m not convinced the two “competing” arguments — justice v. retraumatization — are really in competition. The most effective treatment for PTSD is exposure with response prevention, a process by which the therapist guides the PTSD patient through a retelling of their trauma. this has been shown to be effective in numerous situations, and does not seem to be dependent on the type of trauma causing the problems. If we abstract the individual case to a societal level, we have the tribunals which help the society face their traumatic memories — which may be painful — but come through them to some resolution. Justice and retraumatization, but then resolution.

However, I’m also not convinced that this is what will happen. I actually don’t think that we should expect that either justice or retraumatization will have a significant effect. A tribunal is not exposure with response prevention, particularly since the perpetrator is involved in the tribunal. Justice is good, but it’s not treatment. This is not to say that the tribunal will not make some Cambodians feel better, just that we shouldn’t expect it to cure their PTSD. That Sonis found an inverse proportion between the expectation of justice and PTSD seems evidence to me that people who have PTSD are generally more pessimistic, and that’s not likely to change just because something goes right in their world. This is not blaming the victim, only acknowledging that people with mental health problems see the world with much darker lenses.

Justice is a value in its own right. We don’t need to justify the pursuit of justice with mental health outcomes. It may be that there is some relationship, but they are not the same. Still, I look forward to the next installment from Jeff Sonis to let us know more about the relationship between the two.