Primary Care

It is quite important that health care professionals working in primary care medical settings learn how to identify which patients have survived torture. Once these patients have been identified, it is critical to work with them in a compassionate and competent manner.


Advocacy for Refugees

Katz, Chloe. NC Medical Journal, March/April 2009, Volume 70, No. 2. pp 153-154

In order to appropriately address the acute and long-term health issues of refugees arriving in North Carolina, physicians will be required to augment their current understanding of cultural competency to include topics of conflict-related violence and psychological evaluation.

An Innovative Model of Culturally Tailored Health Promotion Groups for Cambodian Survivors of Torture

Cambodians living in the U.S.A. suffer from depression, posttraumatic stress disorder (PTSD), and chronic medical disease at rates far in excess of national averages. The Harvard Program in Refugee Trauma’s Cambodian Health Promotion Program seeks to address this burden of disease by offering them culturally tailored health education in a group setting.
A health professional and a bicultural health educator co-facilitated a five-session health promotion group for Cambodian survivors of torture from 2007 to 2011. The program covered five major topics from Western and Cambodian worldviews. They 

Can Metformin Buffer the Deleterious Association between Psychological Distress and Glycemia in Patients with Type 2 Diabetes?

Wagner J, Keuky L, Horn I, Schumann K, Scully M, Kuoch T. 

Published in the Journal of Endocrinology, Diabetes & Obesity, September 2015.

The full article is available for free at the link below.


Background: Psychological distress is associated with hyperglycemia in persons with diabetes. Preliminary reports suggest that metformin may help buffer the effects of psychological distress on hyperglycemia. Many Cambodians who are currently over age 35 have elevated symptoms of psychological distress from having survived their country's genocide.

Diabetes Prevention through Village Health Support Guides in Cambodia: A Qualitative Investigation of Opportunities and Challenges

Julie Wagner, Lim Keuky, Lorraine Fraser-King, Theanvy Kuoch, and Mary Scully

Published in Journal of Community Medicine & Health Education April 2015.

Click on the link below for full text or .pdf of the article


Objectives: Lifestyle modification can prevent type II diabetes. Rates of diabetes are high in Cambodia. The Cambodian genocide and its aftermath resulted in destruction of the healthcare system and a critical shortage in the Cambodian healthcare workforce.

Diagnosis and Treatment of Depression in Adults With Comorbid Medical Conditions

By Mary A. Whooley, MD. Published in JAMA, May 2, 2012—Vol 307, No. 17.

Approximately 1 in 10 primary care patients has major depressive disorder, and its presence is associated with poor health outcomes in numerous medical conditions. Using the case of Mr J, a 52-year-old man with depressive symptoms and several comorbid medical conditions, diagnosis and treatment of depression are discussed.

Helping Refugee Trauma Survivors in the Primary Care Setting

Written for primary health care providers who may be treating refugees or other survivors of war trauma and torture. Primary care physicians and providers often must identify and educate survivors before encouraging them to seek mental health services, if appropriate. The manual includes assessment questions for health care providers to ask patients and facilitate the treatment process.

Patient Reported Outcomes of 'Eat, Walk, Sleep': A Cardiometabolic Lifestyle Program for Cambodian Americans Delivered by Community Health Workers

Wagner J, Kong S, Kuoch T, Scully MF, Tan HK, Bermudez-Millan A.

Published inJournal of Health Care for the Poor and Underserved  May 2015.



This study investigated a community health worker-delivered lifestyle intervention for prevention of cardiometabolic disease, called Eat, Walk, Sleep. It was designed for traumatized, low-literacy Cambodian American refugees.


We used a single group, pre-post design to evaluate the effects of the program on self-reported health behaviors.

Primary Care Management of Non–English-Speaking Refugees Who Have Experienced Trauma: A Clinical Review

This article, by Sandra Crosby, MD, is attached, or available for subscribers through JAMA.

Importance  Refugees are a vulnerable class of immigrants who have fled their countries, typically following war, violence, or natural disaster, and who have frequently experienced trauma. In primary care, engaging refugees to develop a positive therapeutic relationship is challenging. Relative to care of other primary care patients, there are important differences in symptom evaluation and developing treatment plans.

Objectives  To discuss the importance of and methods for obtaining refugee trauma

Pulse pressure in Cambodian Americans: relationships to weight and mental health

Wagner J, Rajan TV, Kuoch T, Scully M.

Published in Journal of Immigrant Minority Health December 2013.


Few studies have explored interrelationships among mental health and health status in refugees using objective, clinical data. Pulse pressure (PP) has recently emerged as an easily obtained, strong, independent determinant of mortality. We conducted a chart review of electronic records for 24 consecutive months to investigate PP among Cambodian refugees receiving services at a community clinic in Connecticut, USA.

Refugees' perspectives on barriers to communication about trauma histories in primary care

By Patricia Shannon, Maureen O'Dougherty, and Erin Mehta. Published in Mental Health in Family Medicine, 2012 January; 9(1): 47–55.

Objective This study explores refugees' perspectives regarding the nature of communication barriers that impede the exploration of trauma histories in primary care.

Method Brief interviews were conducted with 53 refugee patients in a suburban primary care clinic in the Midwest USA. Participants were asked if they or their doctors had initiated conversations about the impact of political conflict in their home countries.

Socioeconomic Status, Waist-to-Hip Ratio, and Short-Term Heart Rate Variability in Cambodians with Type 2 Diabetes

Wagner J, Keuky L, Lampert RFraser-King L, Feinn R, Kuoch T, Scully M.

Published in International Journal of Behavioral Medicine December 2015.




Diabetes, adiposity, and socioeconomic status (SES) are all associated with decreased heart rate variability (HRV), a marker of autonomic function predictive of mortality. Cambodians have high rates of diabetes and low SES. How these factors interact to explain HRV has not been examined.


The aims of this study were to investigate associations among waist-to-hip ratio, socioeconomic status, and HRV among Cambodians with

Surviving Torture

by Richard Mollica, MD. Published in the New England Journal of Medicine, 351;1. July 1, 2004.

More than 45 countries are currently suffering from the destruction caused by mass violence.The 20th century has been called the “refugee century,” with tens of millions of people violently displaced from their homes. Millions of these people have resettled in the United States, and refugees, asylum seekers, and illegal immigrants now commonly enter our health care institutions.

Survivors of Torture: Prevalence in an Urban Emergency Department

Academic Emergency Medicine
Volume 19, Issue 10, Article first published online: 25 SEP 2012
Survivors of Torture: Prevalence in an Urban Emergency Department
Braden Hexom, MD, Dinali Fernando, MD, MPH, Alex F. Manini, MD, MS, and Lars K. Beattie, MD, MS
This article examines attempts to estimate the prevalence of survivors of torture presenting to an urban ED. Through data collected at Elmhurst Hospital (home of Libertas Center) in New York, the authors concluded that self-reported survivors of torture did present to that urban ED.

The National Cambodian American Town Hall Meeting: a community dialogue on "eat, walk, sleep" for health

Kuoch T, Scully M, Tan HK, Rajan TV, Wagner J.

Published in Progress in Community Health Partnerships: Research, Education, and Action Winter 2014.



The 2009 National Cambodian American Town Hall Meeting was a public-private partnership convened to address long-term health issues related the Cambodian holocaust. Goals for participants were to dispel myths about diabetes; goals for the partnership were to build research capacity and to strengthen relationships.



Partners collaborated on all aspects of the meeting which was held in Khmer by bridged videoconferencing in 10

Torture and War Trauma Survivors in Primary Care Practice

By H M Weinstein, L Dansky, and V Iacopino; published in Western Journal of Medicine, 1996 September; 165(3): 112–118.

Close to 1 million refugees from around the world have entered the United States, fleeing repression, war, terrorism, and disease. It has been estimated that among these are thousands who have experienced torture. Many refugees and immigrants will appear in the offices of health care professionals with symptoms that may be related either directly or indirectly to torture. Both physical and psychological torture may result in long-term sequelae.

Torture survivors: What to ask, how to document

Miles, Steven H; and Garcia-Peltoniemi, Rosa.

Excellent article for medical practitioners who may not realize that they are treating torture survivors with tips on how to proceed. "In this article, we propose an approach—based on studies that address cross-cultural issues or use multicenter, multivariate, meta-analytic methods—that can enable you to better identify survivors of torture, assess and document consequent morbidities, and refer them to appropriate treatment programs. We focus on individuals who were tortured months or years earlier rather than on recently traumatized patients."

Training Cambodian Village Health Support Guides in Diabetes Prevention: Effects on Guides' Knowledge and Teaching Activities Over 6 Months

Wagner JKeuky LFraser-King LKuoch TScully M.

Published in International Journal of Behavioral Medicine,April 2016.

Type 2 diabetes is a pressing public health concern in Cambodia, a country with limited human resource capacity due to genocide. Cambodian village health support guides (Guides) promote health at the local level.

The curriculum, called Eat, Walk, Sleep was delivered to Guides in Siem Reap province once over 3 h. Participants completed a pretest and posttest on diabetes knowledge.

Trauma, healthcare access, and health outcomes among Southeast Asian refugees in Connecticut

Wagner J, Burke G, Kuoch T, Scully M, Armeli S, Rajan TV.

Published in Journal of Immigrant and Minority Health December 2013.


Mental health problems among Southeast Asian refugees have been documented. However, longer term health consequences of mass violence as re-settled refugees age are less well described. This study investigated relationships among trauma symptoms, self-reported health outcomes, and barriers to healthcare among Cambodian and Vietnamese persons in Connecticut.


Refugee Trauma Survivors in the Primary Care Setting: A Collaborative Medical Mental-Health Approach


  • Describe somatic presentation of war based trauma in primary care
  • Describe the role of primary care providers in working with torture survivors
  • Identify a common clinical flow process that can be used to improve health outcomes and decrease pain
  • Create strategies for co-managing care with a mental health therapist

Summary: This webinar attempts to tackle the difficulties in working with refugees and victims of torture in the medical system in the United States.