Even before the earthquake of January 12th — before the physical, psychological, and social catastrophe that killed as many people as the atomic bombs dropped on Hiroshima and Nagasaki— the psychosocial state of Haiti was extremely fragile. The living ghosts of slavery, terror and exploitation by foreign and domestic powers, political violence in the streets, destructive hurricanes, lack of social infrastructure, near famine conditions…the majority of the Haitian people have been dealing with chronic, elevated life stress for many years. Haitians have undergone a particularly traumatic social history, a collective experience lived out over the course of centuries.
Today, the basics of everyday life are either hard to come by or are simply not available: shelter, food, school, doctors, and clean water cannot be taken for granted. The stress that comes with living under these conditions—traumatic events aside—increases the likelihood that a human being will lose her ability to function as effectively as possible. When a massive disaster such as the 2010 earthquake, which had both natural and man-made causes, is added in to the mix, psychological problems spike. Mental health care in Port-au-Prince today is practically non-existent, a fact that has dire implications not only for current suffering, but one that also increases the probability that psychological problems will be passed down to future generations.
Living in abject poverty everyday and every night tends to take a toll on one’s psychological functioning. According to the UN, 55% of the country lives on less than $1.25/day and 58% of the population is undernourished. When new traumatic experience occurs in such an impoverished environment, the chances of cracks in psychic structures for those vulnerable to mental illness are significantly increased; psychotic disorders, the most severe and dramatic of the mental illnesses, touch approximately 5%-12% of the patients we see here.
Many others are suffering from more difficult-to-see or invisible wounds. The problems treated by our psychologists here, whether directly related to the earthquake or not, have most commonly included anxiety and depressive disorders. Post-traumatic stress and clinical depression are rampant, and loss and pathological mourning have trapped a good portion of the population inside themselves —loss of important people, of structures, of status, of limbs, of way of life, of normal. When trauma and depression intersect, the suffering is compounded.
The earthquake of 2010 is the latest addition to a historical list of severe traumatic stressors suffered by Haitian families. According to psychologist Daniel Derivois, the first trauma was being kidnapped from Africa and forcibly taken on slave ships to work plantations across the Atlantic; each successive trauma has only compounded and crystallized the psychic suffering, effectively amputating the collective memory of the people. The country has become the patient.
Mental illness in Haiti comes with a huge stigma and people here are reluctant to talk about their problems, show emotion, or ask for concrete help, so many suffer alone. A good portion of Haitians somaticize their negative emotional responses to their environment and suffer from terrible headaches, probably the most common presenting complaint at our outpatient clinics here.
Health care in Haiti has traditionally been the domain of Vodoo, the Haitian religious culture derived from West African traditions and French Catholicism. A recent study by the World Health Organization explains that Vodoo:
includes healing practices, health promotion and prevention of illness and promotion of personal well-being… Vodou provides information on how to promote, prevent and treat health problems, with theories of illness, treatment interventions, and prescriptions for behavior that are congruent with widely held explanatory models… A first level of interpretation of illness in Vodou is based on the need to establish a harmonious relationship with the spirit world of the ancestors. A second level deals with the role of magic or sorcery attacks in which the afflicted person is the victim of a spell. According to the causal explanations of Vodou the health and illness of a particular person depends on his or her connection to tradition and place in the social and moral order and in a wider universe of being that includes the ancestors and the gods…Vodou is based on a vision of life in which individuals are given identity, strength and safety in a dangerous world through the thick fabric linking them together with other human beings, as well as spirits and ancestors. For this reason, disturbances in health or luck are a sign that relationships have been disrupted and may need to be mended. Vodou rituals heal individuals and groups “by exercising, strengthening, and mending relationships among the living, the dead, and the spirits”…The only way to control health and luck is through “the care and feeding of family, in the largest sense of that term”… [emphasis added] (“Culture and Mental Health in Haiti: A Literature Review”, WHO, 2010)
The culture of vodoo means that differential diagnoses of clinical conditions in Haiti need to be made with extreme care by Western psychologists and psychiatrists. If a patient in New York explains that he was hit in the face by an invisible man, or that he regularly has visions or sees spirits, he is likely suffering from psychosis and the prescription of neuroleptics would probably be appropriate; if a Haitian says the same thing, however, chances are he is not psychotic but has internalized the norms of his culture and religion. The incidence of certain psychological problems also differs from Western consumer society: We see a lot fewer suicide attempts here in Haiti, as well as less evidence of borderline personality disorder, compared to the United States and Western Europe. On the other hand, hysterical conversions, essentially a thing of the past back home, are not uncommon here.
Besides oungans and mambos, other traditional healers, such as herbalists or leaf doctors, continue to be popular. Fortunately, Western mental health practices can be effectively applied in parallel with folk medicine. Clinical psychology arrived in force in Haiti during the 1980s with the AIDS epidemic—an epidemic probably imported from the US, according to medical-anthropologist Paul Farmer. Today, Haiti claims only about 300-400 undergraduate-level psychologists/psychotherapists, and a paltry 10-15 psychiatrists, for the entire country of 9 million people (in comparison, New York City, which has the same population, has 7000 licensed doctoral-level psychologists, thousands of psychiatrists, and many thousands of other mental health clinicians and unlicensed psychotherapists). The principal Haitian psychiatric center for acute illness, Mars & Kline, brings to mind a 19th century prison in disrepair and the treatment of patients there resembles a form of psychiatry practiced in America during the first half of the 20th century. A lack of sufficient funding means that the families of the destitute and psychotic patients must pay for treatment, adding to their strain.
Trauma symptoms related directly to the earthquake appear to have diminished six months later, yet many of our patients continue to relive this event everyday through flashbacks and other intrusive memories that come imbued with overwhelming anxiety. These images, thoughts, and feelings can be absolutely debilitating. For some patients, the post-traumatic stress remained dormant for months, only to manifest unexpectedly following a more trivial stressor. Sometimes, the experience of internal bodily shaking is still there months later, as if the earthquake just happened a few minutes ago.
Endless stories of trauma and loss can be cited:
For example, there’s the young man who lost his potential girlfriend under his house after she came by to do him a favor; he dug up her body three days later and the image of her bruised and bloody face stays with him; a week after the earthquake, when the girlfriend’s mother tracked him down and called him, he denied who he was and told her she was talking to the wrong person, adding to his incapacitating guilt…. There’s the adolescent sister and her younger brother who left their father’s house to go live with their mother only to have the new home collapse days later on their mom, their aunts and their cousins; Dad has not been heard from since the 12th and the two kids currently live with a man they met that day who offered to help and who has since become the sister’s boyfriend; he beats her and coerces her but there are few other options…There’s the story of the girl who was trapped alive under the rubble for four days with her older sister, their youngest sister’s decaying body lying next to them, literally pressed against the face of the young girl the whole time, imprinting it; they kept their dry lips moist with urine and eventually stopped with the useless screams; the only way to tell if it was day or night above was by the sound of activity nearby…Another girl sang me an unforgettable little ditty that she soothed herself with that night while trapped under her house: “En bas décombres/En bas décombres/En bas décombres …(Under rubble/Under rubble/Under rubble)….”
Treatment methods for psychic trauma vary but usually involve reliving the trauma in a safe environment with goal of learning to cope with the problem-causing memories. Instead of avoiding the difficult images—a classic symptom of post-traumatic stress—the person can habituate themselves and master them. The associated anxiety can also be managed using concrete techniques. In addition, irrational thoughts linked to the psychic trauma (e.g.,“My life is over”,”I don’t exist any more” “I can’t go on”) that lead to more problems can be recognized, restructured and replaced with more logical, realistic and helpful ideas so that the person can begin to actively rebuild her personal and emotional life.
Many problems are more indirectly related to earthquake trauma. For example, one couple—one of the lucky ones with a house and a job— kept the door unlocked so that they could escape easily if another quake hit. Unfortunately a street gang used the opportunity to walk into their house at 2AM, rape her, beat him, and rob them both; they didn’t even have shoes to wear to go to the hospital.
So the crisis continues. More than half of Port-au-Prince still lives under plastic sheeting with a floor of dirt, or in tents that were made to last for no more than six months that are now disintegrating. Entire camps have been forcibly displaced and more people are scheduled to be evicted. Many of these tent cities will be there for years. The heavy rains that have started in the last few weeks—often impressive in their violence and intensity—turn dirt to mud and augment the raw living conditions.
While there have been improvements in lighting, the lack of official or unofficial security in many of the camps remains poor, putting women, and especially adolescent girls, at risk. Unsafe living conditions mean rape is often committed by unknown men, sometimes in groups. According to KOFAVIV, the Haitian commission against sexual violence:
Because of persistent insecurity, people cannot leave their tents at night, feeling obliged to stay inside and stay vigilant because they are scared of violence…children are often left alone, either because they don’t have parents or their parents have to leave to look for food or work…if water is not provided by the camp, young people must leave to look for water for their family, exposing them to elevated risk of rape. (Report on Security in the Camps, 18 July 2010)
While gender-based violence is also epidemic in the US and Europe (perhaps more commonly between two people that already know each other, or have an intimate relationship) the ongoing humanitarian crisis here in Haiti make reports of rape particularly spectacular. Adding to the problem, the instant reintegration into society of thousands of prisoners, including violent criminals, the day of the earthquake, means that criminal violence, especially against women and girls, remains a public health problem.
There is no private life in the camps. Children witness everything that adults say and do, including fights and sex. In addition, according to CATWLACH, an anti-trafficking commission, parents are finding it particularly difficult to control their children due to the inevitable and self-propelling, “homogenous mélange” of kids that forms. They describe social life in the camps in particularly chilling terms:
Children hear, or become a part of, the intimacies of others. Everything is permitted in the camps and is seen by everybody. This means that some of the children who witness hideous scenes committed by adults are subject to repeat them. As a consequence, these children will not have any respect for human dignity. They are losing a real sense of life. Becoming rapists, assassins, prostitutes, or killers will matter little since their life is denied of sense. (“Rapport sur la situation des femmes et des filles dans les camps à Port-au-Prince apres le séisme du 12 janvier, 2010. Mois d’avril et de mai.” La Coalition Régionale contre la Traite et le Trafic des Femmes et des Filles en Amérique Latine et dans la Caraïbes dont Haïti. )
In this way, tent camp life adds more layers of stress to an already fragile population, increasing the likelihood that further traumas will be inflicted in the future, digging deeper at the open wounds.
The mental health team at the World Health Organization is today working with the Ministry of Health and foreign NGOs to build an effective, decentralized mental health care system in Haiti. I had the opportunity to contribute to this project during my nine weeks in Port-au-Prince. The long-term plan is to put such a mental health care system in Haitian hands. Such a transfer is essential. Unfortunately, these hands are currently bloody and bound.
PsySR member Yosef Brody is an American clinical psychologist based in Paris, France, where he teaches and works in private practice. More about his work in Haiti can be found at http://haitijustice.tumblr.com. Yosef can be reached at firstname.lastname@example.org.