They left in small wooden boats, flimsy rafts, inner tubes and anything that would float, hoping to cross the 95-mile stretch of ocean that divides the Island of Cuba from the United States. A total of 32,000 people survived the crossing; of which 2,500 were children and adolescents. It is estimated from past records that only one in three "Cuban rafters" is able to make it alive across the Florida straits. It was the summer of 1994 in Cuba, the 35th anniversary of the communist revolution that elevated dictator Fidel Castro to power. Three years had passed after the collapse of the Soviet Union. Devoid of all types of supplies from the former Soviet Bloc, Cuba was facing its worst financial crisis ever. People took to the streets in desperation, rioting in open confrontations against the much feared police authorities. In order to prevent a blood bath, the communist government of Cuba announced that it would "open the doors to all of those wishing to leave". This proclamation, on August 24, 1994, led to the massive exodus by sea. The U.S. government responded by sending a fleet of Coast Guard ships to the Florida straits, in order to intercept the Cuban rafters in what became known as "Operation Sea Signal" (the largest U.S. naval operation since the Korean War). The survivors were taken to refugee camps inside the U.S. Naval Base at Guantanamo Bay, located in Southern Cuba.

Guantanamo, a hot, dusty desert-like expanse of 42 square miles, was transformed, overnight, into endless rows of military tents, surrounded by barbed wire and guarded by U.S. soldiers wielding combat weapons. I arrived in Guantanamo as a member of the "Miami Medical Team", a volunteer organization that provides aid to victims of war, disasters and to refugees. In one of two "M.A.S.H." units, my colleagues and I worked alongside military medical personnel tending to the men, women and children. Afterwards, we entered the camps to make "home visits" on the refugees. Children and adolescents narrated their stories about the ocean crossing: Many saw drowning people and other rafters being devoured by sharks. Others survived storms at sea and witnessed how family members perished in their arms as a consequence of hunger, exposure, and dehydration. The camps, in turn, were over-crowded, had poor hygienic conditions, and were plagued by heat and mosquitoes.

On November 14, 1994, tropical storm Gordon flooded the camps, blowing away tents and destroying the few remaining personal possessions that had survived the trip. The lack of privacy and the physical proximity to strangers frequently flared tempers, causing riots and fights. Children were exposed to adult profanity, overt sexual activity, suicide attempts, and witnessed violent confrontations among the refugees. American soldiers in full riot gear, raided the tents at night, looking for weapons in an attempt to "weed out criminals and undesirables" who were purposely planted among the refugees by the Cuban government, in order to sabotage the process. Once identified, these individuals were separated and transferred to a different camp, designated for this purpose. As days turned into weeks and weeks into months, the refugees found themselves beset by idleness, uncertainty about the future and lack of schooling for their children; which worsened feelings of anger, desperation and depression. The chief military medical officer on the base began raising serious concerns about the emotional welfare of the children. With his encouragement I formed a team and conducted a study in which 300 refugee children and adolescents reported alarming rates of bed-wetting, soiling, nightmares and aggressive behavior. They reported feeling a constant state of terror due to the confusion and uncertainty. The preliminary results were sent to the U.S. government in Washington. This, and many other lobbying efforts by the media and government officials who constantly visited the camp, culminated with an announcement by President Clinton that the U.S. agreed to the "unconditional acceptance" of all children, adolescents and their families. The slow bureaucratic process however would take almost another year to complete.

The majority of the Cuban refugees established themselves in South Florida, where they felt comfortable among the strong and welcoming Cuban-American community. Many already had relatives in the area. Once in Miami, we conducted a second study of the refugee children attending transitional summer schools sponsored by the Catholic Church, in order to facilitate their adaptation to the American public school system. We found that in the first eight months of arrival in the U.S; between 40-60 percent of the children continued to experience moderate to severe symptoms of Post-Traumatic Stress Disorder, when reporting on themselves. However, in the same study, none of the school teachers reported noticing any overt emotional or behavioral signs of distress in the same children. These findings are very similar to those found among other groups of children exposed to traumatic situations. That is, that the signs and symptoms of emotional trauma are usually experienced subjectively and frequently go unnoticed by those who care for the children. Although the majority of children tend to adjust well over time, studies have also shown that children subjected to traumatic situations are at a higher risk of developing mental health problems, such as depression and substance abuse, upon reaching adulthood.

Emotionally traumatized children can often become socially isolated and tend to daydream excessively. Some may become pessimistic and feel hopeless about the future. They may appear sullen, moody and irritable. Sometimes they can become aggressive over minor provocations or may act in a childish manner by becoming disruptive and provocative. Many have difficulty with concentration, since they are tormented internally by threatening memories and anxiety. This may account for poor academic performance of some, in spite of possessing above average capabilities. Internal distress also places adolescents at risk of substance abuse, in an attempt to self-medicate. Since many of these symptoms are indistinguishable from those found in any other troubled child, only matching the background history with the symptoms will identify the children at risk. Undoubtedly, children with a positive history of trauma and the above mentioned symptoms, should be immediately referred to the school's mental health counselor. Teachers play a critical role in identifying these "at risk" children; since, many times the parents are overwhelmed with their own traumas and by the stresses brought on by acculturation into the new country.

Five years later, the majority of the Guantanamo Cuban refugee children appear to have adapted well and to have joined the mainstream American society. Some have already been featured in articles by the local media, after having excelled academically and artistically. But "emotional casualties" have also resulted from the process. In the end, each child will find their own personal meaning in the experience. What is certain, however, is that all of them will carry those memories with them for the rest of their lives.

Eugene Rothe, M.D. of Key Biscayne, Florida, is a Fellow of the American Psychiatric Association.