A random system? How Norway (fails to) organize health services to rehabilitate torture survivors

Post co-authored with Moa Nyamwathi Lønning, PhD.

In a fresh off the press article in Journal on Rehabilitation of Torture Victims and Prevention of Torture, Inga Laupstad, Ann Evy Aasnes and ourselves address the provision of rehabilitation services for torture victims in Norway. We engage the topic on three levels: a review of relevant rehabilitation rights and duties, a presentation of the organisation of rehabilitation services in the Norwegian public health care system, and importantly, an evaluation of professional experiences from practice. Our focus is on the plights and rights of migrants who have experienced torture before crossing the Norwegian borders, and is based on qualitative interviews with 46 experts and practitioners across Norway’s four health regions.

We find that the rehabilitation services for torture victims in Norway are fragmented, knowledge is lacking, and the resulting practice highly person dependent.

Background and Norwegian Context

As employees at the Norwegian Red Cross, we started this project in 2019 with a well-founded concern that individuals who have experienced and survived torture before entering Norway don’t receive the rehabilitation that they need and have a right to. Together with the Church City Mission, the Norwegian Red Cross runs two healthcare centres for undocumented migrants in Norway. In contrast to the public health care services, these centres provide health care for undocumented migrants free of charge and with no threshold for treatment. In 2018, 16 percent of the patients at the Oslo centre reported that they had been subjected to torture.

While torture is forbidden in all forms, the International Rehabilitation Council for Torture Victims (IRCT), the largest umbrella organisation for centres and programmes for torture rehabilitation, estimated in 2010 that there were over 400,000 torture victims in the European Union alone. Within Norway, we only have pre-2015 estimates of how many individuals live with the experience and consequences of torture, at 35,000. We know that the share of torture experiences is particularly high among refugees, and expect the number to be significantly higher today, following the so-called refugee crisis from 2015 onwards.

When examining the rights and duties for rehabilitation in a Norwegian legal context, different international human rights treaties are relevant. One of these is the International Covenant on Economic, Social and Cultural Rights’ (ICESCR) (1966) Article 12, stating that every state should “recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”. Another is the UN Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment’s (1984) Article 14, which states that:

Each State Party shall ensure in its legal system that the victim of an act of torture obtains redress and has an enforceable right to fair and adequate compensation, including the means for as full rehabilitation as possible.

In Norway, the national health care service is the main provider of rehabilitation services for torture victims. In practice, this implies that those with a right to a general practitioner (GP), must approach their GP and get possible referrals to the specialised health care services from there. It also means that they are liable for a user fee until they have paid the annual maximum fee (NOK 2,460 in 2020) and receive an exemption card. This contrasts with the situation at specialised centres elsewhere that provide services free of charge, for torture victims (for instance, Freedom from Torture in the UK), for traumatised refugees (for instance, Dignity in Denmark) and for persons with a refugee background more broadly (for instance, the Red Cross in Sweden).

Despite the system, not because of it

Some of the professionals we interviewed for this study have employers who see the value of their dedication and allow them the necessary time and resources to respond to patients’ complex trauma. Alarmingly, however, many of the 46 Norwegian experts we interviewed, do what they consider their professional duty and moral responsibility towards patients with torture experiences despite the work conditions and frameworks provided by the Norwegian public health care system, not because of it. Several competent professionals stretch far beyond their roles and pay rolls to address the needs of torture victims they meet in their professional capacity. Rather than shying away from a task too tall to handle, they have developed skills and expertise through perseverance, personal initiatives, international networks, and profound dedication in order to help those who have trusted them with their experiences. Overall, we find that torture victims with a refugee background in Norway are far from ensured a satisfactory rehabilitation service.

Fragmented services

Firstly, services are fragmented. There is a general lack of coordination and inclusion of actors that would contribute towards a satisfactory and comprehensive rehabilitation process. As one of the psychologists we interviewed about the organization of services put it: “The so-called Norwegian model [is not] a model. The Norwegian system is a random system.”

Lack of knowledge

Secondly, there is insufficient knowledge about torture and torture injuries among service providers. Relevant services are characterized by insufficient knowledge about ‘torture’ as a topic, and unfamiliarity with international protocols for identification, examination, and rehabilitation – as encapsulated in the Istanbul Protocol. The challenge of identification is illustrated in this quote by a psychologist we interviewed:

Many of my patients were very much in doubt whether I could bear to listen to what they had been subjected to […] Would I be able to listen and to carry the burden of knowing about it? If they told me, would I break into pieces? They did not want to expose me to the strain of listening to what they had been subjected to.

If you do not know what to look for, if you don’t provide a safe space for sharing, and do not ask directly, it is not likely that torture injuries are identified or understood. Our mapping of the content of the professional studies for medicine, psychology, and nursing, revealed that students of these professions receive little to no training on the subject. Without knowledge about torture injuries, it becomes extremely challenging to undertake good identification – a precondition for rehabilitation to take place at all. As a consequence, identification of torture injuries appears arbitrary.

Person-dependent services

Thirdly, the rehabilitation services that are provided, are person dependent, rather than the result of systematic organization or prioritization from national authorities. This is true at all levels, from identification and documentation to treatment and rehabilitation. Practitioners who strive to ensure local rehabilitation services describe a powerlessness when faced with a system that does not facilitate comprehensive rehabilitation. This is arguably the most challenging aspect of providing help, treatment, and rehabilitation to this group.

Health service illiteracy and inaccessibility

Finally, torture victims with a migrant background experience the same barriers that immigrants in general share in accessing public health, care and welfare services, such as different understandings of health, a lack systemic knowledge and health literacy, in addition to issues related to language, inadequate translation services and incorrect use of translators by service providers.

Recommendations for a better rehabilitation service

In order to secure rehabilitation for torture victims in Norway, the shortcomings of the current rehabilitation ‘model’ needs to be addressed. To this end, we propose the following three measures to ensure minimum standards in rehabilitation services in Norway:

  • The Norwegian authorities should develop a national plan of action on torture rehabilitation to secure a systematic, equal, and comprehensive rehabilitation service to people who have survived torture, the
  • Knowledge about documenting, identifying and rehabilitating torture injuries should be included in relevant educations including, but not limited to, medicine, nursing, physiotherapists, psychologist, occupational therapists, dentists, interpreters, social workers, lawyers, and police. In addition, competence should be strengthened in existent service provisions.
  • Specialised and interdisciplinary competency about torture rehabilitation, as regards all levels of service, should be strengthened and gathered in one or more institutionalised professional groups, teams and networks that coordinate and communicate knowledge to strengthen existent and decentralised services.

Want to read more? The article is available, open access, here – as is the Norwegian Red Cross report produced for a Norwegian audience.

3 thoughts on “A random system? How Norway (fails to) organize health services to rehabilitate torture survivors

  1. “16 percent of the patients at the Oslo centre reported that they had been subjected to torture.”

    That is ghastly, and a very large number.

    I wonder how many citizens of ‘host’ countries, or particularly of rich, mostly non-hosting countries, like the USA, where I am a citizen, know of this fact?
    I’d like to hope that knowing this, knowing how large a percentage of refugees have been tortured, and thus are fleeing not only for their lives, but for more than that, would affect opinions on receiving refugees?
    Thank you for this information, Anette, and for this article.
    -Shira

    • Thank you for your feedback and comment, Shira. It is a staggering number, indeed. I have to point out that this number reflects the patient population at the Health centre for undocumented migrants – that is, migrants without residence permits (permanent or temporary) – and not refugees as such. I wonder if the share would be even higher among refugees with permits.

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