James Lavelle and Svang Tor of the Program in Refugee Trauma display a drawing depicting the maltreatment that refugees sometimes face. Photo by Jon Chase.

The scene is sickeningly familiar: columns of exhausted, frightened refugees line the road for miles, a river of human misery. They have been forced from their homes at gunpoint and robbed of everything they owned. Some have been beaten, raped, or tortured. Some have seen their spouses or parents murdered. They have watched their villages burn to the ground as they fled.

This is Kosovo. But it could just as well be one of 60 other countries that have been torn apart by mass violence since World War II. In the past decade alone, 10,000 people per day have been forced to flee their homes, according to United Nations estimates. Worldwide, 50 million people are living as refugees or are displaced within their own countries.

Thanks to the efforts of international agencies and humanitarian relief organizations, the refugees -- those who manage to reach the camps across the border -- will probably survive. There they will be reasonably safe from further violence and will receive food, shelter, and medical treatment.

Once the emergency is over, however, the media will rush off to the next crisis and the relief organizations will fold their tents, leaving the refugees alone to rebuild their shattered lives. Not surprisingly, many will be unable to do so.

The Harvard Program in Refugee Trauma (HPRT) at the Medical School is one group that is trying to help. For nearly two decades, HPRT has been leading the effort to heal the survivors of mass violence.

Twenty Years of Dedication

Richard Mollica, James Lavelle, and Svang Tor came together in the early 1980s, when all three were working with Southeast Asian refugees in New England.

In 1978, Lavelle, now director of International Programs at HPRT, had been running a community mental health project in Providence, R.I., where there was a large Cambodian community. This was just before the world discovered the truth about Pol Pot's campaign of terror.

"I was hearing horrific stories. I was talking to people who were identified as patients, but had clearly just walked out of four years of genocide," Lavelle says. "These people weren't 'mentally ill' -- they just had the normal response to an extremely abnormal situation. They had blown their fuse."

Lavelle and Mollica, associate professor of psychiatry at the Medical School, met in 1981 and started the Indochinese Psychiatry Clinic in Brighton. The clinic is still operating, now as part of Beth Israel Deaconess Medical Center in Boston.

A year later they were joined by Svang Tor, a counselor who now serves as training coordinator for HPRT. A quiet, dignified woman with a ready laugh, Tor is herself a former refugee. She was a schoolteacher in Cambodia and survived the slaughter and the concentration camps that claimed the lives of her husband and one son, as well as 3 million other Cambodians.

HPRT has been working on many fronts. In addition to its clinical work, the group has conducted pioneering field research in Cambodia, Rwanda, and Bosnia to better understand the long-term impact of trauma on refugee populations.

HPRT has also created programs in war-ravaged countries to train local health care workers to treat trauma-related illness. In doing this, they always work in partnership with medical schools and institutions in the affected countries. This past December, graduation ceremonies were held in the Angkor Wat temple for the first class of 100 Cambodian primary care doctors who completed a comprehensive training in mental health.

The Long-Term Cost of War

One of HPRT's biggest challenges has been trying to persuade the international community that the problem exists.

"The international mandate for refugees has been based on the model of protection," says Mollica, director of HPRT.

"But it's a static model. The long-term impact on these people of the searing experiences they've been through was never addressed. If people looked like they were doing well physically, that was enough. The mental health effects were completely ignored.

"There's an attitude that human beings are like rubber bands -- that you can subject them to all this stress, and when the crisis is over, they'll just pop back to normal again. This is completely false. These people have been severely traumatized. If you look 10, 20 years down the road, it's the mental health effects that are producing most of the disability, increased mortality, and morbidity. Say you have 3,000 women who have been sexually brutalized. That's a 50-year problem. That's not going to go away."

In a recently completed study of Bosnian refugees living in exile in Croatia, investigators found that half the refugees suffered from depression and post-traumatic stress disorder several years after their ordeal.

But the diagnosis is not the point. "We're not trying to pathologize this as a psychiatric problem," Lavelle says. "The fundamental question is, how has this trauma affected people's ability to function in the long term, to be productive members of society?"

According to Mollica, "The disability is potent and very long- lasting. These people can't live independently; they can't restore their families; they can't work or be good parents; kids can't learn in school. If you want to reconstruct lives and societies after the refugee crisis, you have to deal with this."

A Proposal to Help in Kosovo

Efforts to get mental health onto the agenda of relief organizations have often been misunderstood. "We're not talking about giving psychiatric counseling to half a million people in the middle of a war," Lavelle says. "But we can use what we've learned about how people respond to adversity."

"There are practical things that could be done right now in the Kosovo region," he adds, "in the acute crisis stage, things which would prevent many of the problems you're otherwise going to have in 10 years."

HPRT has, in fact, just presented a proposal for a project in Kosovo, and a team is preparing to visit the region to assess the situation. Mollica outlines some of their principles:

"First, you have to keep families together. One thing that just happened in Macedonia -- a terrible tragedy -- we're hearing of kids separated from their moms and dads. That happened in Rwanda, and it was a disaster.

"Second, people need to be involved in solving their own problems. Building houses, making latrines, whatever -- they need to contribute." International relief programs typically put refugees in a position of total dependency. Partly for political reasons, refugees are not allowed to work or go to school, and they have no money of their own. "We know that [that situation] is a major risk factor for mental illness," Mollica says. "It further undermines their dignity and creates a sense of powerlessness. And this happens in every refugee camp."

Third, he says, people need to be allowed to celebrate their religion. "There's a lot of ambivalence about this because religious differences often play a role in the conflict. But how can a 12-year-old organize the fact that his mother and father were murdered in front of him? Belief systems are the single most important resource people have."

Finally, Mollica stresses the need to pay special attention to the most vulnerable groups -- the elderly, children, adolescents, and rape victims -- and to support indigenous healers. "There are doctors and psychiatrists in the refugee community, but they usually never get to do anything. Involving them in the crisis stage is a chance to prepare them for what they're going to face when the relief teams leave." Mollica continues: "These are basic principles of mental health that have been completely ignored in the past." Will it be any different this time? Says Lavelle, "We're pathologically optimistic."