I inspect my patient from head to toe and then left to right across her body, noting ridges of scar tissue. “His machete,” she says. Dime-sized wounds are scattered across her thighs. “His cigarettes,” she explains.
I marvel at the elasticity of skin, the regrowth of hair, the capacity of body and spirit to prevail and heal.
After an hour, I set down my camera and ruler. My patient embraces me in a tight, tearful hug.
“I am free to let go now,” she exhales. “You’ve captured it all.”
Capturing it all — the aftermath of kidnapping, gang rape, forced genital mutilation, and torture by government officials — is my work. As a forensic nurse examiner trained to provide trauma-informed care for individuals who have experienced violence, I document my patients’ past physical abuses to be included in applications for asylum.
In most ways, I’m very different from my patients. I was born in the U.S. and am privileged enough to have academic and professional degrees attached to my name. Yet I identify with their need for authentication, validation, and substantiation.
When I first set out work with asylum-seekers in Baltimore, I was excluded from what was a physicians-only class and dismissed by its organizers as “just a nurse.”
I was, indeed, a nurse. But I was a nurse who had recently returned to the city after living on Iraq’s Syrian border where I managed women’s protection and empowerment programs at a large refugee camp. And I was caring for a steady stream of patients at a Baltimore hospital who had reported recent sexual assault, domestic violence, and elder abuse.
My city is a major resettlement site for refugees, and home to many immigrants. Yet the patients I was seeing didn’t reflect this diversity. I knew that immigrant and refugee women were particularly vulnerable to violence upon resettlement in the U.S. Where were they?
With grant money from the Johns Hopkins Neighborhood Fund, I hosted a community open house at the hospital where I worked. One of the attendees was an immigration attorney. “Our clients have injuries from violence that happened months or even years ago,” the lawyer told me. “Can you help us with that?”
Could I? I had the education and experience. Yet at the time, physical evaluations of that sort were typically performed by volunteer physicians who took a one-day course in forensics. The instruction was modeled for doctors, ostensibly shutting out nurses like me.
Neither surprised nor dissuaded, I enrolled, only to find that the one-day lesson paled in comparison to the rigorous, 80-plus-hour hands-on training that had previously earned me licensure as a forensic nurse, a nationally recognized title. The merit of the lesson was that it validated the skills I already had to address the unique post-assault needs of immigrant and refugee survivors.
As one of 28 million nurses around the globe who provide more than 80% of the world’s health care, I am responsible for ensuring the well-being of not only my patients, but also my profession, which historically is underrepresented within forums that set global, national and local health agendas. Too often, nurses are still viewed as helpmates instead of as a distinct profession that can and does practice with autonomy. The contributions of nurses — 90% of whom are female — are sidelined; our capabilities, undervalued.
That nagging reality will be brought into sharp focus this week with the publication of the World Health Organization’s report “State of the World’s Nursing.” Analyses of comprehensive data and contemporary evidence from more than 190 countries offer a real-time snapshot of what many of us know: Nurses do much of the work of health care yet occupy relatively few positions of leadership or authority to drive the changes we know our patients need. Too many of my colleagues, from Baltimore to Bengaluru and Afghanistan to Zambia, lack even fair wages and safe work places free from harassment, discrimination, and violence.
The United Nations has set ambitious health-related goals to be achieved by 2030, one of which is ensuring healthy lives and promoting well-being for people of all ages. That can happen only if nurses are equipped with the education and regulation they need to practice to the fullest extent of their abilities, and only when they are recognized as being not just good enough, but good. Period.
Being dismissed as “just a nurse” when I sought the training required to do forensic examinations didn’t stop me from moving forward. I partnered with two local legal organizations serving immigrant clients, the Tahirih Justice Center and Kids in Need of Defense, to pilot a program for a nurse-led model of care at my hospital: They sent me referrals, and I performed the evaluations and well as trained another nurse to do them.
Two years later, our program demonstrates that nurses are, in fact, well-positioned and wholly qualified to provide forensic evaluations, not only for criminal courts but also for immigration proceedings. We have offered this service for women and men from Honduras, Guatemala, El Salvador, Bangladesh, Rwanda, and Nigeria.
Affidavits based on forensic evaluations can make all the difference for survivors seeking asylum in the U.S. Nationally, about 35% of asylum-seekers are granted asylum, while the success rate for those with legal representation and supporting clinical forensic documentation can be nearly five times higher.
The first client I ever had was granted asylum — her reality vindicated. So too was my professional truth: Nurses need to take the lead on the frontlines of care so billions can benefit in countless ways.
Jennifer Breads, R.N., is a global health workforce adviser for Jhpiego, a maternal health organization and affiliate of Johns Hopkins University, and a forensic nurse examiner in Baltimore.