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Prescriptions for Sanctuary

A lot of things seem to walk away from Katalin Roth’s office, which, she admits, is “due for a clean.” But a simple greeting card isn’t one of them. She locates it swiftly, plucks it off the bulletin board, and reads it aloud.

“Thank you very much for everything you have done,” it says. “You saved my life. As a Burmese, I worship you every day for saving my life.”

“Isn’t that amazing?” Roth says. “It’s the most amazing card I’ve ever received.”

Roth is the division director of geriatrics and palliative medicine at the GW Medical Faculty Associates and an associate professor in the Department of Internal Medicine at the School of Medicine and Health Sciences (SMHS).

As a doctor, she is in the business of saving lives. As a volunteer medical evaluator of asylum seekers, she helps refugees like the card’s author — a journalist who fled a country where her profession is considered criminal — create new ones. Her two roles are not that different. After all, as Roth wrote in a paper published in the Journal of Pain and Symptom Management, “helping a refugee achieve legal status in this free country is really to save a life.”

The word asylum literally means sanctuary. Legally, it is the right to remain in the United States despite an expired visa or illegal entry, and the ability to eventually apply for U.S. citizenship. Symbolically, it means freedom.

But no matter how it’s defined, achieving asylum isn’t easy.

To earn it, asylum seekers (also called asylees) must prove refugee status — that is that past persecution or a well-founded fear of future persecution prevents them from returning to their home countries, and that such persecution is based on race, religion, nationality, political opinion, or membership in a particular social group. Because asylees often lack documentation, an affidavit and/or testimony from a medical evaluator like Roth can be the difference between life and death.

Roth conducts her evaluations at Bread for the City, a nonprofit clinic that provides comprehensive services, including food, clothing, medical care, and legal and social services, to vulnerable District residents. She takes a medical history, conducts a physical examination, and asks a lot of questions — about the abuse, the escape, detention conditions, and methods of torture. She asks about life “before” and life “after.”

The most important part of Roth’s job is the listening. It’s also the hardest.

She has heard stories of rape, beatings, starvation, and burning; tales of amputated fingers, crushed legs, stretched arms, and sliced skin. She has documented genital mutilation, chronic fungal skin infections, and severe arthritis.

Though not all scars are visible, the stories are chilling. These injuries are not accidents. They are deliberate and cruel and, perhaps worst of all, they represent only a fraction of the tortures inflicted daily in more than half the world’s countries. Those who make it to Roth are the lucky ones.

“You learn a lot about how terrible people can be to one another,” said Roth, who has examined people from the Ukraine, Georgia, Pakistan, Ethiopia, Albania, Sudan, Guatemala, and more. While in the clinic she remains calm and sympathetic, but detached, “later, in the privacy of my home,” she says, “I have shed tears,”

But Roth’s tears are fleeting. The people are inspiring, interesting, and often very brave.

“They have the courage of their political convictions and stand up to governments,” she says.

Roth’s first patient came to her by way of her colleague Julia Frank, M.D., associate professor of Psychiatry and Behavioral Sciences in SMHS, who had been performing psychiatric evaluations of asylum seekers for about five years.

Annie was a “thin, frightened young woman” from Cameroon who had been arrested and abused in prison presumably because her boyfriend was a political activist. With the help of Frank and Roth’s documentation, Annie was eventually granted asylum and is now a home health aide, a wife, and a mother.

“While working with Annie, I discovered a new dimension of myself as a physician,” Roth says. “I had been a physician-advocate before … but in this work, I can help individuals also address international injustice.”

Roth also shares a personal connection with the refugees. Her family survived persecution as Jews during World War II in Hungary and then fled the country when she was three months old because her father, a small business owner, was a capitalist in a communist regime.

"I grew up hearing the stories of our escape, about the bullets that whizzed by as the truck driver drove through a checkpoint, and the fellow passenger who was killed in the escape," Roth says. "So I know firsthand…that immigration is a choice one makes when one has no other choices."

Roth’s experiences with refugees are valuable in the clinic, where she argues that doctors know too little about their patients.

“We don’t ask the veterans what happened in the war, whether it’s World War II, Korea, or Vietnam. We don’t really ask foreign-born patients what kind of turmoil they went through. And so we miss out on knowing our patients,” she says.

Physicians also risk missed diagnoses. Depression, stomachaches, irritable bowel syndrome, headaches, and eczema can all be related to past traumatic experiences, Roth says.

And for those who have been traumatized, medical care can actually be unnerving. Clinic rooms can remind them of prison. Clinicians’ questions can echo interrogations, and medical tools can resemble mechanisms of torture.

It’s a concept best illustrated by one of Roth’s patients, a 70-year-old Vietnamese-American man named Nguyen who was crying as he recovered from lung surgery. Nguyen told Roth he was not in pain — as long as he remained still. And yet, lying still was almost worse: The position reminded him of the torture he had endured as an anticommunist in South Vietnam, where he was confined to a cage for six months, unable to stand.

“Nguyen helped me understand how helplessness can be recreated in the medical setting and how easily long-buried memories of torture can be reawakened in illness,” says Dr. Roth.

Back in her office, minutes before reading the greeting card, Roth received a phone call that a patient in her geriatric clinic had died. She empathized with the caller, admiring the deceased, and wishing the family her best. With the click of the phone and a mark on her chart, another patient was lost forever.

As a physician, Roth is also in the business of watching lives pass.

“It’s sort of an antidote, I guess,” she says as she pinned the card back on the bulletin board.

In Roth’s world, even when lives are lost, there are always more to save.

This story was originally published in the Spring 2011 issue of Medicine + Health magazine. To view the magazine, go to Medicine + Health.com