A Student-Run Asylum Clinic to Promote Human Rights Education and the Assessment and Care of Asylum Seekers

Tens of thousands of individuals flee human rights violations in their home countries and seek asylum in the United States every year. Less than 40% receive protective status, leaving many torture victims rejected. However, 90% of asylees receiving a medical-legal affidavit are granted asylum, although demand for medical evaluations far exceeds the supply of trained clinicians. By establishing asylum clinics at their medical centers, medical students and licensed clinicians can improve the probability of an asylee obtaining asylum, connect them to vital services, and train more clinicians in their area to address the demand for evaluations. Asylum clinics are also unique educational opportunities for students interested in global health, social justice, and human rights. They operate by pairing student volunteers with clinician volunteers to meet with an asylum seeker for an evaluation. The evaluation involves extensive history-taking, a psychological exam, and a physical exam to note consistency between objective findings and the client’s story. The volunteer team then drafts a medical-legal affidavit for use by the client’s lawyer in immigration court. There may also be post-evaluation follow-up and connection with healthcare or other social services. Students at the Georgetown University School of Medicine (GUSoM) established an asylum program in 2014, hosted two training workshops, and have begun accepting clients’ requests for evaluations. The GUSoM Asylum Program’s operations (including organizational structure and logistics of evaluation), educational opportunities (including mentorship and global health competency), and goals (including increasing capacity for evaluations and further developing partnerships with local stakeholders) are detailed below.


Introduction
Every year, millions of individuals flee their homelands where they suffered persecution, illtreatment and torture due to their sexuality, gender, political identity, religion, race, and more.In 2014 alone, 13.9 million people were newly displaced, either inside their home nation as internally displaced persons (11 million), or as refugees or asylum-seekers (2.9 million). 1Upon leaving their home country, tens of thousands of displaced persons seek legal asylum in the United States, with nearly 100,000 applying for asylum in 2013. 2 Unfortunately, the bar for obtaining such legal status is exceedingly high, and only as few as 38% of applicants receive any form of protective status, asy-lum or otherwise. 3However, for asylum-seekers receiving a medical-legal affidavit, the likelihood of receiving protective status jumps to 90%. 4 Organizations such as Physicians for Human Rights (PHR), Human Rights Watch, and the Torture Abolition and Survivors Support Coalition (TASSC) have for years partnered with physician, psychologist, and social worker volunteers (hereafter referred to as clinician volunteers) to provide physical and psychological evaluations of asylum seekers.To perform an evaluation, a trained clinician volunteer meets with an asylum seeker to obtain an extensive history.Then, he/she performs physical and psychological exams to corroborate subjective claims with objective findings in accordance with the Istanbul Protocol established by the United Nations High Commissioner for Refugees in 2004. 5During the evaluation, examiners make particular note of behavioral and physical signs of torture and trauma, such as symptoms of posttraumatic stress disorder or specific-appearing scars.Volunteers then draft a medical-legal affidavit for use by the client's lawyer in United States Asylum Court in support of the asylum-seeker's claims of torture and maltreatment.In some cases, the clinician volunteers may be asked to testify before the court regarding their professional opinions of the client's history of torture and maltreatment.In this way, clinicians can leverage their expertise for the benefit of an overwhelmingly underserved population.
Recently, several medical centers, including those at Weill Cornell Medical College, the University of Pennsylvania, and the University of Michigan, have formalized their partnerships with organizations providing asylum services in the form of student-run asylum clinics. 6Student-run asylum clinics have multiple benefits for various stakeholders: 1) for clinicians, shifting responsibility for a significant amount of time, organization, correspondence, and affidavit drafting from individual clinician volunteers to students, enables professionals to perform evaluations more frequently; 2) for asylum seekers, linking them to other needed services and teaching clinicians to perform evaluations to help meet the high demand for evaluations; 7 3) for students, whose involvement brings with it mentors, educational opportunities in global health, human rights, research, social justice, and advocacy, and leadership opportunities in curriculum design and operations management.
In late 2014, students from Georgetown University School of Medicine (GUSoM) founded their own asylum clinic in Washington, DC, in partnership with PHR and the Georgetown University Medical Center (GUMC) Departments of Family Medicine and Psychiatry.As of this writing, two volunteer training sessions have been held, and affiliated clinicians have begun accepting clients through the clinic.The stated goals of the GUSoM Asylum Program are to improve the quality of life for victims of torture and persecution by bolstering their efforts to obtain legal asylum, connect them with vital healthcare and living services, and spur interest and investment in refugee health among burgeoning medical professionals.In the sections that follow, we will describe the organizational and operational model of the GUSoM Asylum Program and outline opportunities for education and development.

Program Overview and Operations
The GUSoM Asylum Program is led by a dedicated team of student coordinators.
The leadership structure of the GUSoM Asylum Program is team-based rather than hierarchical (Figure 1).Two student coordinators take responsibility for individual cases, pairing clinician volunteers with student volunteers and organizing the meeting with input from the client and his/her representative.Following the evaluation, a continuing care coordinator works with the student volunteer to connect the asylum-seeker with free healthcare and social services available in the District of Columbia (DC) Metropolitan Area.Additionally, two education coordinators plan regular training sessions for volunteers, as well as multiple educational seminars for students throughout the year.These leadership teams meet regularly with each other to discuss needs, updates, and changes.They also regularly receive input from an advisory board made up of former coordinators and the program's faculty advisor.
The essential elements of the operations of the GUSoM Asylum Program are communication and flexibility.It is the leadership team's responsibility to coordinate amongst the many stakeholders involved in an evaluation, so timely communications turnaround is a must.Furthermore, this process is ever-evolving: the team is constantly looking for ways to improve the quality of communication to save time and effort.For example, in the past, separate coordinators have been responsible for communication with either clinician or student volunteers, rather than separating responsibilities by individual cases.It was through process of trial and error that the program arrived at the its current structure.The entire process of providing evaluations is described in detail below: Scheduling the Evaluation 1.Every month, organizations like PHR and the TASSC contact the GUSoM Asylum Program with a list of asylum-seeker evaluation requests in the DC area.2. A scheduling coordinator emails a roster of trained clinicians (family medicine, psychiatrists, psychologists, social workers) and requests that they choose a case and suggest a date and time for the evaluation.3. The same scheduling coordinator sends the clinician's availability to the client's representative and a date and time is agreed upon.

This is a graphical representation of the roles held by team members and their relationships to various stakeholders involved in the GUSoM Asylum Program. These stakeholders include the Georgetown University Center for Applied Legal Studies (CALS), the Torture Abolition and Survivors Support Coalition (TASSC), and Physicians
for Human Rights (PHR), as well as the asylum seekers and volunteers themselves.hours.The clinician takes a history, including a life history before the maltreatment, the events surrounding the maltreatment, and the time between leaving the home country and arriving in the United States.The clinician then performs a physical and/or a psychological evaluation.3. The student volunteer takes notes using a standardized evaluation form as a guide.4. At the end of the visit, a list of local resources is given to the client, and the clinician makes suggestions about continuing care. 5.The student volunteer and the clinician meet afterward to compare notes and debrief.

Leadership Team
Affidavit Writing and Follow-up 1.The medical student volunteer drafts the affidavit and submits it to the clinician.2. The clinician edits the draft, finalizes the medical affidavit, and submits it to GUSoM PHR, the PHR Asylum Network, and/or the client's representative.3. The continuing care coordinator contacts community resources on behalf of the client.
The student volunteer and continuing care coordinator contact the client directly at various points over the following months and serve as a resource for the client.

Educational Opportunities
Not only is the Asylum Program an excellent resource for victims of torture and maltreatment in their quest for legal asylum, but our student and clinician volunteers also reap significant educational rewards for their work.One of the goals of the GUSoM Asylum Program is to provide a practical experience in human rights, global health, and multicultural education for the benefit of future medical practitioners.Our model of student education at the GUSoM Asylum Clinic is presented in Figure 2.
Debriefing sessions with volunteers have demonstrated that many of these educational goals are being met, with the hope that they will ultimately translate to the potential outcomes described above.Our students have appreciated the opportunity to put the legal knowledge of human rights they obtained by participating in the volunteer training session into practice.One student, for example, recognized the importance of the provisions of the Violence Against Women Act of 1994 in extending legal protection to her client.Students also report an increased understanding of cultural and global health issues.For student volunteers, the biopsychosocial model of health determinants becomes a much more practical model of considering health issues through their involvement in the medical evaluation and affidavit process.Furthermore, participation in the GUSoM Asylum Program takes place within the broader context of a Human Rights Curriculum organized by the education coordinators for volunteers and the general student body at GUSoM.Students attend lectures in the humanities and medical sciences related to human rights, with topics ranging from artistic representation of torture to physical diagnosis of trauma scars.Ultimately, medical students interested in working with asylum-seekers will enter their profession with important skills and an appropriately-developed knowledge base.
Finally, our student volunteers are exposed to the often horrific tales of torture and maltreatment recalled during asylum evaluation encounters.Though there is a known risk for vicarious trauma, 8 we believe that students may benefit from a process of "vicarious resilience" -the countertransference of resilience that often takes place in the course of an evaluation and its potential impact on our volunteers' insight and empathy.Many of our clients remain resilient and optimistic despite having endured harrowing traumas.Volunteers report being inspired by the spirit of the asylum-seekers they meet, as well as gaining renewed respect for the suffering of others.It is our hope that this appreciation will translate into retained  Understand the importance of followup care and barriers to integration and acculturation The tasks required of student volunteers directly contribute to the educational goals of the clinic, which are designed to promote global outcomes benefiting the volunteer's future clinical practice and investment in asylee health.These tasks also have practical utility for clinic operations.
empathy as our student volunteers develop into medical professionals.

Budget and Finance
The operating costs for the GUSoM Asylum Program the GUSoM Asylum Program are small (Table 1): roughly $2,500 (depending on the number of participants) is spent on the fall training workshop, which provides training for both students and clinicians.This $2,500 pays for food, materials (including the Physicians for Human Rights Examining Asylum Seekers manual), and honoraria for guest speakers and workshop leaders.A similar but smaller spring training costs roughly $1,000.These workshops are financed by participant tickets of $65, although costs may be decreased by omitting Examining Asylum Seekers manuals and organizing fundraisers in partnership with local businesses.Finally, campus-based educational events for students are scheduled throughout the year, and in total have a capped cost of $350 or less.These events are financed by funds from the Georgetown University School of Medicine Executive Council, which provides funding for events for registered student organizations at the medical school.On occasion, faculty grants helped cover some of the costs of the training.
Currently, there are no direct costs associated with providing the asylum evaluation itself, other than in-kind contributions of clinicians' time at their local clinical site of practice, because no administrative or nursing support is needed at the clinical sites.
Finally, we also plan to intensify our grant-seeking and grant-writing efforts, in anticipation that grants would enable us to provide training for volunteers free-of-charge and enhance other activities.In addition to fiscal benefits, grant-writing is an important educational and career-development activity for students, and we plan to make this a top priority in the future.

Development and Future Directions
As a new endeavor at Georgetown University, development of the Asylum Program has been the primary focus over the last year and will continue to be a major priority in the future.The GUSoM Asylum Program depends on its student and clini- cian volunteers; without students, clinicians must spend a cumbersome amount of time writing the affidavit, diminishing their capacity to volunteer; and medical evaluations can only be done by licensed clinical professionals who volunteer their time.To meet the large volunteer requirement for operating the clinic, two extensive training workshops were held in the past year to equip students and clinicians with the skills necessary to perform evaluations and write affidavits.In the first workshop, we successfully trained 25 students to complement the handful of GUMC employees already trained to evaluate asylum seekers; at our second workshop, we trained 5 new clinicians in the performance of psychological evaluations.These daylong training workshops include the following modules: an introduction to the legal asylum, workshops for recognizing signs of physical and psychological trauma, an affidavit-writing workshop, a presentation on the "tips and tricks" best practices for performing an asylum evaluation, and an introduction to the GUSoM Asylum Program.We plan to continue hosting training sessions every six months to continue to build our capacity for asylum evaluations.
Another focus in developing the clinic has been fostering partnerships within the DC/Maryland/Virginia region to improve our ability to connect clients with much needed health and wellness resources.It is important to note that the GUSoM Asylum Program is not a point of care.In order to meet our clients' great need for psychological and physical treatment, as well as social services, the clinic must be connected with outside resources equipped to provide such care.Therefore, the leadership team has made it a priority to develop professional relationships with such care entities in the DC/Maryland/Virginia region, including, but not limited to the TASSC; the Unity Clinic, a system of health centers that provides care regardless of ability to pay; and the GUSoM student-run HOYA Clinic, which provides walk-in outpatient services to the uninsured and homeless in Southeast DC.It is the responsibility of the student volunteer and the continuing care coordinator to ensure that the client has the information necessary to seek out treatment in these locations; it is common for the continuing care coordinator to call ahead and ensure that client will be able to access care.
In addition to expanding partnerships with organizations throughout the region, the GUSoM Asylum Program is working to enhance interprofessional collaborations through joining forces with other schools within the University.The Georgetown University School of Law has a program which aids asylum seekers with the legal issues involved in the asylum process, and we are currently working out the logistics of a partnership.Additionally, we are reaching out to nursing students and professionals at the Georgetown University School of Nursing and Health Sciences to expand our ability to meet the continuing care needs of our clients.

Discussion
As the world responds to the worst refugee crisis since World War II, we expect the number of individuals seeking asylum in the United States to increase.One way of responding to this large scale emergency -especially for those not meeting criteria for refugee status and resettlement -is to increase the number of organizations and medical education institutions who can step forward with ways to help these people gain protection within our country's borders. 9Through the creation of a student-run asylum clinic, GUSoM has recently joined a growing number of medical schools leveraging their healthcare expertise, clinician connections, and student volunteers to aid the asylum process through medical evaluations and affidavits.This article has highlighted the unique role of student-run asylum clinics and detailed the operations of the GUSoM Asylum Clinic.We hope to encourage continuous dialogue and exchange of ideas as more medical schools, as well as other health profession education institutions, begin responding to the growing number of individuals hoping to obtain legal asylum in the United States.

Table 1 .
GUSoM Asylum Program Sample Budget