Dissociative Disorders and Children

Evidence of dissociation in KHA's patients is most dramatic in adolescents who were born during the Pol Pot Regime. During one family session a rebellious, "Americanized" teenaged girl who had no memory of Cambodia turned into a drooling, stuporous child as her mother described the death of her brother during the Pol Pot Regime. A major conflict developed between parents and the child protection workers who saw the girl as being a victim of her parents inability to acculturate. An evaluation done by a child psychiatrist did not include any mention of dissociation and identified the girl as having an adjustment problem. The report also did not include a trauma history. In a variation of this same theme, a heavy set Cambodian boy terrorized his teachers and then turned into a clinging, frightened child when he was with his parents. He was able to function well in a structured environment but became belligerent and hyperactive in a mainstream classroom.

Another boy in this age group was suspended from school after sexually assaulting another student. His rationale for the attack was that a friend ,"told me to do it." This boy scored a 4 on the HIP (Hypnosis Induction Profile) The lack of memory of the child's own trauma experiences has led many to believe that the trauma is inconsequential to the development of behavior problems. Short attention spans have been reported by many teachers of children who were born during the Khmer Rouge or in refugee camps. Attempts to have these problems evaluated have proven troublesome, as the children were either considered uncooperative or the testing was not considered valid based on culture.

In a survey of Southeast Asian adolescents in Rhode Island, Diane Brouusseau Pizzi questioned high school and middle school girls about their memories of war in Southeast Asia. While 100% of the Cambodian high school girls thought about the war, only 33% thought that others Cambodian adolescents thought about it too. These same children identified their parents as talking about the war only once in a- while. As with other survivor groups, there is the unspoken suggestion that no one is to speak of this subject which plays such a major role in the lives of survivors. Khmer Health Advocates frequently encounters families in which the children have no idea of the circumstances of their resettlement in the United States. One young man who is from an ethnic Lao family from Cambodia had no idea that he came from Cambodia or that his twin brother had died during the Khmer Rouge. He always thought that the reason his mother never came out of her bedroom was because he made so much trouble for the family.

In a study of startle respones of Cambodians traumatized as children, female survivors demonstrated an unusual lack of physiologic response to a startle paradigm. (Wright et al. 1994) This brings into question the accepted understanding of the adaptation process in trauma victims and validates the complexity of evaluating the traumatized Cambodian child. Dr. Robert Krell, a child psychiatrist and expert on Concentration Camp Survivors has pointed out that most children who survived concentration camps have remained silent about their experiences. "Their memories, rather than fading with time, have intensified ....Parents and even psychiatrists do not credit child survivors with their ability to remember. As a result, child survivors have difficulty verifying their memories and have spoken very little about them." Many years after their trauma experiences, child survivors are having breakdowns and instrusive memories. (Krell et al. 1990).

Parents and teachers describe personality changes in young adults that leaves them baffled and uncertain how to deal with them. While the extreme trauma experienced by many children, early in their development years, would lend itself to multiple personality disorder, there are no published studies of this condition in Cambodian children. However, Dr. William Sack and his associates have clearly identified PTSD in a longitudinal study of Cambodian adolescents and have verified the cross-cultural appropriateness of this diagnosis. In a chapter of a bilingual book called, Harvard Guide to Khmer Mental Health, Richard Mollica writes, "Cambodian leaders who have worked with Khmer refugee children have observed that children who have the greatest stress express it by an inability to concentrate or sit still. This has been affirmed by lay workers and border officials in the camps. All felt that the most disturbed children had the following symptoms: poor concentration, distractibility, inability to focus on learning, nervousness, constant movement and anxiety." These observation were made while children were in a continuing traumatic environment. How are these symptoms interpreted when the child is far away from their trauma experience? How many of these symptoms are due to organic changes similar to those of adults.

Neurological Disorders

The availability of sophisticated diagnostic tools have again shifted the focus of survivor studies back to organic origins of symptoms. Recent studies of combat veterans and Concentration Camp Survivors have shown what are believed to be trauma related changes in the hippochampus that are associated with problems of concentration and short term memory in survivors. (Bremmer, 1995) The Indochinese Psychiatric Clinic is presently completing a indepth evaluation of fifty Cambodian Survivors who were given a complete neurological exam including an MRI, SPECT scan and EEG. "Preliminary results indicate that a history of torture is associated with hidden or undiagnosed traumatic brain injury which may be interfering with postive response to psychiatric treatment."(Mathias, 1995) Combat veterans have been the focus of many studies since the Vietnam Veteran Project began in the late 1970's and early 1980's. Neuropathy was found in Prisoners of War which is believed to be due to nutritional deficiencies. (Hong,1986) Neuropathy including optic atrophy and sensorineural deafness is associated with the starvation conditions of the Prisoner of War experience.(Gill, G et al., 1981) The magnitude of the health problems of survivors of Concentration Camp experiences makes the further exploration of the co-existence of physical illness overwhelming. Again, the interaction of the body and mind must be respected to fully comprehend the struggle of the survivor.

Communicable Disease

Upon their release from Concentration camps, up to 18% of survivors had active tuberculosis, report Eitinger & Strøm; many more died from it before release from refugee camps in 1949. Years later, Strøm (reported in Thygesen et al) found that 14.5% of survivors still had active tuberculosis cases. There are severe longterm effects of tuberculosis that persist even after recovery. Cambodian refugees entering the United States were required to complete treatment for active TB prior to their arrival. In 5 studies completed between 1980 and 1984, Cambodians with a postive TB skin test numbered between 39-57% of those screened. (Erickson, 1980;Cantazaro, 1982; Sutherland et a, 1983; Barry et al) Infectious hepatitis is prevalent in ap-proximately 14% of Cambodian refugees and Cambodians have a carrier rate 3times that of the general population.(Cantezaro 1982; Judson, 1984) While statistics are rare that include the ethnic subdivisions, the California tumor registry showed a high proportional incidence ratio of liver cancer in Cambodian men. While this does not necessarily indicate a higher incidence rate, it does indicate cancer sites that should be targeted for intervention in the Cambodian population. Hepatitis was a major cause of illness in POW's who were interned in the Japanese camps. Evidence of hepatitis B was found in 20% of these POW's. It is estimated that approximately 10% of those with hepatitis B have gone on to have severe problems with their liver. (Venn, 1991)

Many investigators have reported on the high incidence of ulcers and diarrhea among survivors of the Nazi concentration camps. Eitinger & Strøm reported that 20% of exprisoners had ulcers or other peptic disorders compared with 8.6% in the matched control sample, and with much greater severity. They find similar results with regard to other digestive diseases. Thygesen et al, in a study of 373 former prison-ers, find ulcers with incidence of 25% and periodic diarrhea with incidence of more than 50%. Cirrhosis of the liverÑmore commonly associated with alcohol abuseÑis also a sequel of starvation. Thygesen et al list several studies that indicate cirrhosis of the liver as a major cause of death among survivors.

Gastrointestinal disorders

Gastrointestinal disorders are seen extremely frequently in KHA's patient population. Symptoms include bloating, heart burn, constipation and diarrhea. These are among the most difficult symptoms to alleviate and KHA knows of no patient who has been symptom free following treatment. At the same time, many patients experience an increase in PTSD symptoms associated with an episode of GI disturbance as well as an increase in memories of starvation trauma . This combination of symptoms often causes internists to dismiss the physical symptom and attribute it to psychological factors.

The H.phylori bacteria , now known to be an important factor in the development of ulcers and gastric inflammation is more prevalent in unsanitary living conditions, a uni versal exper-ience for survivors. Although cancer statistics often do not include ethnic subcategories, it should be noted that stomach cancer is part-icularly high in Asian women. There is also an association between H. pylori infection and a higher incidence of stomach cancer. In view of recent information about ulcers, as well as studies that show that such conditions as tropical sprue are found in POWs and travellers as long after their exposure, it would seem reasonable to suspect organic causes for chronic gastrointestinal distress.

The high rate of hepatitis B in Cambodian survivors also must be considered when they complain of digestive problems. Liver cancer and cirrhosis are becoming increasingly more common which is consistent with findings about POW's and Concentration Camp Survivors. While digestive problems may be due to past starvation, it must be noted that survivors are also found to have parasites more than 10 years after their resettlement. (Lurio et al, 1991) Intestinal parasites commonly cause bloating and GI distress. Prevalance rates of parasites in newly resettled Cambodian refugees were extremely high with 67% of a large study having one or more parasite. Hookworm is the most common parasite in Cambodians and is a major cause of anemia. In this same study, 48 % of Cambodians screened had anemia.(Catazaro et al. 1982) In reviewing medical records, KHA found a number of survivors who have high eosinophil counts and who have had their GI symptoms dismissed as being stress related.

Bones, Muscles and Nerves

Malnutrition and starvation can lead to various disorders of the skeletal system caused by decalcification, according to Deveen. Rheumatism, osteoporosis, and other disorders are reported with great frequency in the literature. These disorders develop slowly, and are often confused with natural aging. But epidemiological evidence shows that concentration camp survivors experience much earlier onset (premature aging) of these skeletal diseases. Thygesen et al detail a number of studies that show early onset and extreme severity of these diseases; Eitinger & Strøm found 47.5% inci-dence of musculoskeletal diseases, much greater than average severity. Eitinger & Strøm pointed out that musculoskeletal diseases can be very debilitating, and thus a major factor in many survivors inability to maintain employment. Khmer Health Advocates reports almost universal experience of body pain in adolescent and adult survivors.

The most common pain is in the shoulders with periodic numbness in the hand and arms. Leg cramps are also a problem that survivors frequently do not mention as they consider them a simple fact of life. In a study of 100 Concentration Camp Survivors, "2/3 of the 100 patients have suffered considerable discomfort from "radicular" pains and paresthesia, pains in the neck and arms." according to Grønvik. Chronic pain play a big role in sleep problems and often gets overlooked in light of the overwhelming symptoms of PTSD with the accompanying nightmares and night terrors. The inefficiency of sleep is noted in several studies of PTSD and undoubtedly plays a major role in the experience of fatigue. In light of liver problems, there is also a concern that Cambodians rely heavily on acetominophen for pain and alcohol for sleep, a potentially deadly combination.

Metabolic Disorders

Definitive studies of concentration camp survivors that associate thyroid disorders with trauma have not been found. However, more recently, abnormal thyroid studies have been associated with trauma. KHA notes abnormal T3 and T4's, in patient records and has had several patients with goiter. Large numbers of female survivors were reported to have very noticeable hair loss, including bald spots. This problem is extremely demoralizing for women who feel that it is a continuation of their de-grading existence during the Khmer Rouge. Metabolic disorders were commonly found in Concentration camp survivors as well as sur-vivors of famine. Some correlation has been found between survivors of famine and the development of diabetes. The only study of the incidence of diabetes in Cambodian survivors is a study of gestational diabetes which is ex-tremely high among Cambodian women. KHA believes the rate of diabetes to be high in Cambodian survivors and questions whether changes in blood sugar can account for some of the high incidence of headache, dizziness and fatigue.

Chronic Disabling Conditions

Chronic health problems as well as signs of premature aging greatly diminish the quality of life for survivors. Vision changes were prevalent in concentration camp survivors with the early development of cataracts due to nutritional deficiencies. Cataracts are extremely prevalent in young and middle age Cambodians and while the prevalence of cataracts is common in Asia, KHA suspect that the incidence in Cambodian survivors is higher than usual. The distress from these eye conditions is often not mentioned until the survivor is unable to work or take care of their chores. Among other vision problems are the reports of psychosomatic blindness among Cambodian women in California as reported by RozeeKoker. This report identifies a significant number of women who have no organic evidence of blindness, but nonetheless are unable to see. KHA has many patients who complain of vision problems and although they never describe blindness, they commonly describe their vision as being dim. In a review of medical records, KHA has found that several of these patients have been diagnosed as having psychosomatic blindness by ophthalmologists. The low incidence of reported cases of psychosomatic blindness in states other than California may be due to the priority of symptoms for which survivors seek treatment.

Hearing problems are another chronic condition which have both a physical and psychosomatic basis. Symptoms of "ringing in the ears" or "hearing a buzzing noise" are very common as well as an almost universal complaint of vertigo, true dizziness rather than lightheartedness. Hearing loss due to chronic infections are common and noted in the literature of Cambodians survivors, however, little is known about inner ear conditions. Studies of Concentration Camp Survivors indicate that syncope and Menieretype attacks were common. The majority of KHA adult patients report "hearing sounds or noise" that can be annoying or distressing. On questioning, some patients will confide that they believe the sounds to be the voices of ghosts and when asked for details, they are able to identify the voices which are most often associated with a trauma event. This leads to the speculation that auditory flashbacks are a much more common symptom than originally observed.

Likewise dental problems with loss of teeth and gum disease certainly take a toll on the digestive system and must be considered when evaluating digestive problems. The loss of teeth are also associated with blows to the head from assaults or injuries as well as a neglect of dental hygiene during the Pol Pot Regime and afterwards due to the prohibitive costs of dental care. The widespread use of betel nut which is chewed like tobacco coats the teeth with a red-black film which is believed to protect them from decay. This practice is most common in middle age to elderly women and has been associated with cancer of the mouth.

Other mysterious symptoms include severe motion sickness that can prevent survivors from seeking medical care or having a social life as the trip to the doctors office or to the wed-ding is so distressing that it is not worth the effort. The complexity of Cambodian survivors health problems are overwhelming. Even under the best of circumstances where there are sensitive, trained translators and health care providers familiar with severe trauma, treatment is complicated and long term . As survivors of torture, it is often terrifying for Cambodians to undergo having blood drawn or CAT scans that enclose them in a small space. Medications are unfamiliar and frightening to people who hear rumors of addictions and complications of using traditional and western medicine together.

Psychosocial Problems

Psychosocial problems are as complex as medical problems, but again they mirror the problems experienced by Concentration Camp survivors and POW's and torture victims. The depression and disability, often unrecognized by society, of Concentration Camp Syndrome can push some to commit suicide. Thygesen et al report a striking number of suicides among Danish survivors, and Eitinger and Strøm note that suicides were unusually common among Norwegian survivors over 50 years old. We have no known statistics of the suicide rates in Cambodians, but have knowledge of deaths from suicide in Connecticut, Rhode Island and Massachusetts as well as attempted suicides among Khmer survivors, especially among unaccompanied minors.

Violence has long been a part of Cambodian life and survivors often have their trauma experiences re-enacted in the home and on the streets. In California, Cambodians have been rumored to have the highest murder rate of all of the Asian groups. Statistics from the Department of Corrections in California show that 40% of the 64 Cambodians presently serving sentences in prison are there for killing some-one. Another 11% are there for assault Despair and violence are most obvious in areas with large concentrations of Cambodians such as Southern California and Lowell, Massachusetts where incidence of murder are often stunningly shocking in their brutality. A mother shot through the heart while nursing her baby, three children attacked and murdered with a machete by a boyfriend who feared being rejected.

Domestic violence and child abuse are common in every state but access to the numbers of families experiencing these problems is very difficult to obtain. Arrest records do not indicate when assault is committed at home. Statistics from state agencies designated to protect children are more difficult to obtain as they are not uniform in their categorization of ethnic groups. Sam Chittapalo, the Asian Affairs Liaison officer with the Long Beach Police De-partment says that there are 2,762 cases of Cambodian families currently involved with the Division of Children and Families because of juvenile problems, domestic violence and child abuse. Malis Oeur Chum in a chapter on domestic violence in the Harvard Guide to Khmer Mental Health describes the process in which families experiencing domestic violence isolate themselves. She speculates that the community does not interfere because of a fear of retaliation. (OeurChum, 1996). Revenge for all manner of slights, real or imagined, are a major cause of assaults in the Cambodian community.

In Cambodia, domestic violence is considered to be at epidemic levels. A research project funded by the Montreal based International Devel-opment Research Center and carried out by the Ministry of Women's Affairs and the Project Against Domestic Violence found evidence of as many as a quarter of a million women seriously injured by domestic violence. Essentially one out of six women is a victim of this problem Sima Wali reports that research conducted by Refugee Women in Development finds that women who were raped during their escape from their country are more likely to be victims of domestic violence.(Wali, 1993) Trauma victims need for control is cited as an important aspect of domestic violence and loss of control is often felt to be life threatening. Without question, dealing with this issue is only the beginning of a long process of unraveling the threads of violence which have plagued Cambodian families for more than a quarter of a century.

The expression of violence is found in all age groups. Among Cambodians, youth gangs are common and violent, perhaps replacing the youth groups of older siblings. The gang problem is most serious in Long Beach, California, where, according to Detective Sorensen of the Long Beach Police Department, there are about 30 homicides involving Cambodian gangs each year, and continuous violence between the Cambodian gangs and the Hispanic gangs. The gangs also target Khmer businesses and families for robbery and extortion. The gangs are beginning to spread beyond their birthplaces: Detective Sorensen tells of gang members traveling across the country to escape the police, who simply join gangs again in their new home. Khmer Health Advocates is aware of gang related assaults and deaths in New York, Rhode Island, Massachusetts and Connecticut. Cambodian adult survivors see gangs as a continuation of the Khmer Rouge influence, stealing their children and turning them into strangers, a problem compounded by the very real language barriers between the generations.

Substance Abuse

Alcohol abuse is commonly associated with depressive symptoms and nervous problems. Eitinger & Strøm found that concentration camp survivors were ten times more likely to be alcohol abusers, based on hospitalization. Their study methods revealed only the most severe cases, but still 17% of their subjects were alcohol abusers in Norway, where laws against alcohol are strict. Cambodians face many of the same risk factors, and KHA can anecdotally confirm that alcohol abuse is a problem among Khmers based on our own observation of many cases. Among Cambodian survivors there is evidence of a growing alcohol and drug problem. One study identified a drinking problem among Cambodian women in Massachusetts (D'avanzo et al, 1994 ) and a MICAS needs assessment showed that drinking is considered to be a major problem identified by survivors.

Khmer Health Advocates has no doubt of the severity of the alcohol problem but without concrete data is unable to determine how much of the alcohol abuse is an attempt to control symptoms of PTSD. What proportion of alcohol abuse can be traced to familial predisposition and what belongs to trauma? It is interesting to note that in the UNBRO report for 1987, intoxication was listed as one of the leading causes of death in women. In considering the long term health of survivors, it also must be noted that there is an extremely heavy dependency on smoking in the Cambodian population. While the largest number of smokers can be found among males, wo men are also smoking in large numbers. Smoking was used as a means of controlling appetite during the Pol Pot Regime and its comforting role makes it extremely pernicious as an addiction. In light of a high incidence of asthma and TB, there is no question that smoking will greatly diminish the quality of life for survivors.

Access to Care

Problems with access to care have been a continuous problem for Cambodian survivors and a costly problem for tax payers. Lack of trained medical translators has caused health care providers to depend on expensive and often mean-ingless laboratory testing which frightens survivors and deepens the barrier to communications. Likewise, test results are often not communicated to the patient or are meaningless to them within their cultural concept of illness. This causes many survivors to avoid seeking Western treatment or to be non-compliant with a plan for follow up care. Many survivors rely on traditional medicine or pseudo-traditional medicine to cure symptoms.

Traditional healers find it difficult to practice in the United States as they do not have access to herbs or the ability to support themselves while they practice their healing rituals. The mental and spiritual preparation necessary for being a traditional healer is difficult in the United States. Experienced traditional healers have a clear understanding of what symptoms they can cure and what conditions need referral for Western treatment. The emergence of "quacks" who claim to have traditional medicine to cure survivors symptoms is prevalent and costly to families who are living below the poverty level. Nonetheless, KHA has seen families that will spend $100 for a vial of medicine to cure stomach distress or will spent $500 for a transfusion in New York's Chinatown. Use of these methods often postpones treatment for serious conditions or threatens the compliance with Western medicines. It also potentially puts Cambodians at risk for AIDS because of the circumstances surrounding intravenous medication use. Cambodians are often secretive about the use of these methods as they feel that Western providers do not understand "Cambodian" illness.

The United States is one of the few countries in the world that has not had the experience of war within its borders in this century. Health care providers have little experience with conditions associated with war trauma and are able to refer combat veterans to federal hospitals for treatment, reducing the necessity for expertise in this area of medicine. Conditions associated with starvation are also rarely seen in general practices and few practitioners think of nutritional disorders when they hear symptoms of headache, dizziness or numbness or are evaluating attention deficits and memory disorders.

Cambodian survivors often associate the telling of their trauma stories with past exper-iences. Biographies were compiled during the Khmer Rouge Regime for the purpose of finding "enemies of the regime" and people who provided inconsistent stories were often executed. During the refugee camp experience, immigration officers were also threatening or abusive to refugees whose stories were told in an inconsistent manner, a pattern often seen in severe trauma. Likewise in a health setting, survivors often feel threatened as well as overwhelmed by the need to provide complex details in a limited amount of time, usually without a trained translator. They get little comfort from a declaration that this is nothing wrong with them based on a lab test. A review of medical records of KHA patients reveal that few health care provider elicit information about trauma experiences. This may be due to a concern about stirring up painful memories, but most likely, it is based on difficulty with communications and the length of time it takes to describe a complex health history.

While KHA has no statistics on the numbers of Cambodians without health insurance, within the Cambodian community in Connecticut only a handful of people are presently receiving public assistance and medicaid. The vast majority are among the working poor who work several low paying jobs many of which may offer health insurance, but only for the worker and not their family. KHA has also seen instances when survivors were able to see a doctor, but could not afford medication. In states with small refugee populations, there are often no support persons to help people find available resources. Studies of managed care in relationship to immigrants and refugees suggest that this system of health care has increased the barriers to access for non-English speaking people.( Chicago Institute on Urban Poverty, 1996)

Prevention

The disability rate of Concentration Camp Survivors was at least 80% according to most studies. (Eitinger, 1973) How many of these disabilities could have been prevented with prompt treatment and prevention of secondary health problems? Issues of liability often send research money into the areas of identification of disorders and their cause and little money into preventing the secondary conditions associated with extreme trauma. There are several areas of prevention which could in fact prevent many health problems and save survivors and their families needless pain. Without question, programs that addresses substance abuse in the survivor population could pay for themselves 100 times over in what it would save in treatment and family dysfunction.

At the present time, the HIV/AIDS prevalence rate in Cambodians is so low that it is almost impossible to get funding for prevention programs that target Khmer speakers. This is despite the fact that the country of Cambodia has one of the highest rate of growth of new cases of HIV/AIDS in the world today. The WHO puts the numbers of HIV infected people at 150,000. The Southeat Asian Health Project identified 48% of prostitutes being HIV positive. Cambodians from the United States are travelling back to Cambodia in large numbers and are at great risk for contracting strains of HIV/AIDS that are presently rare in the United States. A needs assessment done in Connecticut in 1995 showed that 65% of the 30 Cambodians who were interviewed believed that they had little or no chance of getting AIDS despite the fact that more than 90% believed that it was moderately common to very common for men to have sex outside of marriage. ( Dyton, 1996)

Prevention of child abuse and domestic violence should be a priority in communities with histories of trauma. The cost of family investigations, foster care, court cost and incarceration cost in relation to domestic violence and child abuse are known to be extremely high, but there is no known study of the prevalence and cost in the Cambodian community. Prevention of mental health problems is not an area that receives funding in this population despite the high incidence of mental health problems. One of the few Khmer language videos available about mental health problems was produced by Amos Deinard of the University of Minnesota and addresses depression and PTSD using survivors who tell their stories and describe their symptoms. This video has been extremely valuable in dispelling the idea that people are alone in their suffering, but unfortunately, too few resources of this nature are avail able.

Prevention of communicable disease, cancer, hypertension or stroke is funded at a minimal level or is nonexistent in some states, even though prevention would probably save many lives and certainly prevent costly disabilities. Without skilled Khmer speaking outreach workers, it is highly unlikely that TB or hepatitis prophylaxis is possible in a culture that does not conceptualize the existence of disease without symptoms. Refugee camps had a high suc- cess rate in completing prophylaxis as they operated direct observation treatment and saw their patients on a daily basis. The need for research on cardiovascular disease is extremely urgent to identify why Cambodians have such a high stroke rate. Is it due to cardiac arrhymias, stress or head injury? Would taking an aspirin a day help to prevent stroke in the survivor population? It would be tragic if a lack of research prevented relatively simple interventions which could prevent costly long term illness.

Issues

Over the past decade, the dramatic increase in applications for SSI by Cambodian survivors has prompted a concern that Cambodians were feigning illness in an attempt to receive benefits. The Government Accounting Office pub-lished a report published in 1994 that was a response to the dramatic increase in applications for SSI from the refugee communities across the country. This report identified a problem with "middlemen" who charged survivors larges amounts of money to help them apply for SSI. These middlemen often gave false information in order to assure that the person qualified for benefits. While the report was able to identify Khmer speaking conmen who fraudulently made money at the expense of refugees, they clearly laid the blame for this fraud on a lack of professionally trained translators. The report found no evidence of fraud on the part of the Cambodian survivor applying for benefits. Nevertheless, the issue of refugee fraud was the focus of several television news stories that were both inflammatory and misleading.

Without question there are always some people who will attempt to beat the system. However, KHA believes that the level of disability is considerably higher than that represented in SSI statistics. KHA has had numerous experiences with survivors being rejected for SSI based on evaluations that were made without the use of translators at all. One elderly man who had a stroke was declare fit to work because his blood pressure was under control. The neurologist who examined him failed to determine that this man had no idea of where he was, who he was living with or what year it was. In several other cases, Cambodians were declared cured of psychiatric disorders because they were taking medication and despite documented evidence that the person was still symptomatic. If these Cambodians did not have the support necessary to demand a hearing and if they did not have extensive documentation to present to the evaluator, they would have been rejected. In most cases, applicants simply give up after they receive a rejection letter. Two KHA patients received letters that stated, "your doctor says that you have depression but have been successfully treated for this disorder." referring to KHA when in fact, KHA documents said exactly the opposite.

On an even more dramatic note, KHA has seen evidence of medical neglect and malpractice in two cases in which people died because of a lack of medical translators. Medical records indicated that the treating physicians did not perceive themselves as having the responsibility to obtain a medical history prior to treating critically ill patients because the patient did not speak English. In fact in one record, the only reference to a concern about a communication problems was the documented irritation of the doctor when no one in the refugee's home could speak English.

To date, KHA knows of no recent comprehensive health needs assessment that has been completed in the survivor population. Problems presented by patients suggest that many families have members who are housebound and unable to seek medical assistance at all. Likewise, patients who have the most disabling symptoms are also those who are too disorganized to consistently return for follow up care. Alcohol abuse, gambling, promiscuity, domestic violence and child abuse are social prob lems which are often precipitated by Concentration Camp Syndrome but quickly stigmatize the patient as being untreatable. Without adequate outreach services, these patients are difficult to follow and usually become involved with the legal system. Because of language and culture, those survivors who are disabled are often shut out of rehabilitation services. The "either or" nature of the disability status also makes it impossible for disabled individuals to function at their maximum level. There are no provision in the SSI status which allows for partial disabilities or disabilities which are chronic but not necessarily constant. Cambodian survivors today are sick and injured and struggling to stay alive. Social Security Supplemental Income is not compensation, it offers the average Cambodian about $450 a month and limited access to health care, hardly an excessive contribution to the lives of "those who have suffered so much and so much."

The Future

Sixteen years after one of the greatest tragedies in modern history, Cambodian survivors are fading into obscurity. As this report is being written, textbooks in Cambodia are being rewritten and reference to the bloody reign of the Khmer Rouge is being removed. Only three short months ago, the United States Congress denied the reality of the Cambodian experience by simply changing their status from refugee to alien and declaring them ineligible for Social Security Supplemental income and Medicare. Survivors themselves live in fear of retaliation if they speak of their experience and identify their persecutors. It is within this context of denial and fear that Cambodian community workers and health care providers face the overwhelming tasks of addressing complex problems with diminishing resources. Those who care for suvivors of massive trauma must now take on the role of witness and advocate in order to alleviate pain and improve the quality of life for people who most certainly have earned entitlement to care.