Reflections on Haiti

Outside the Port-au-Prince International Airport, I looked around and I could sense the psychological pain many felt. People were running to help with our luggage, just for a small tip. Some were as young as 10 years old! So many people were on the streets due to homelessness and unemployment. Many just felt safer staying outdoors since the earthquake. This broke my heart! The psychosocial stressors were so evident and profound.

Two jeeps took us from the International airport to a smaller one for a domestic flight from Port-au-Prince to Cap-Haitian. During the flight, I observed the tent cities, the devastation of the flora, yet still there was a beauty in the country. Once we arrived, I felt devastated by the number of youngsters who were begging on the streets in front of the airport. The streets were overcrowded. The roads were destroyed. I thought to myself, "Is this my native town?" Cap-Haitian was a strip of land between the beautiful dark green mountains in the North and the West and the Bay on the East. When I was a kid, it used to be a must-see tourist spot in Haiti, receiving two to three cruise ships a week and everything was neat and clean. People were friendly, proud, and dignified.

From the Cap-Haitian airport, we traveled to Milot. It was a 30 to 45 minute drive on a bumpy dirt road. We arrived in at around 7:00PM. I was surprised to see the number of missionaries from so many different organizations who were there. I was introduced to an American psychiatrist, who told me she has worked in many other disaster areas around the world. We discussed our work agenda for the coming week.

My first patient was an 11-year-old who had a left femur fracture. She was reported to be an orphan. Her chart from 1/12/10 reported bedwetting, fecal incontinence, seizure, pseudo seizure, hallucinations and mental retardation. She had refused to eat and clean for two weeks. She was screaming sporadically. It was difficult to figure out what she was saying. She hid under the bed sheets. She was pale and looked dehydrated. Another volunteer and I tried to get her to sip some water. She didn't want to. Then I said "dlo," which means "water" in Creole. She looked at me, took a sip, then drank the full cup, then an additional cup. She randomly used a few words, apparently not for communicative purposes. She told me her mother's name, her grandmother's name and her brother's name. She told me she has never been in school because of the illness. Which one? Some people thought she was hallucinating. Her history prior to the earthquake was totally unknown. For a minute, I felt inadequate. I missed the Child Protective Services and the social workers. I missed having a pediatric nurse, a neurologist, or a lab. Later on, Madhu, an OMAT pediatrician missionary, teamed up for the case. She requested an X-ray that demonstrated a fracture on her leg with perpendicular displacement of the nail previously placed. The girl shrieked, due to her feelings of intense pain. With proper management of her pain with some Toradol medication, she was finally able to eat and sleep. I visited her, worked with her and advocated for her daily. The day I left, she was still waiting for an orthopedist missionary from the United States to perform a second femoral surgery. There were also talks to transfer her to the Dominican Republic or the United States for that surgery. She had become the main subject of conversation between the pediatrician and me. I thought, "Wouldn't it be great to have a rehabilitation center dedicated for these children earthquake victims?" I will never forget that girl.

Michael, an OMAT family practice physician from Canada consulted me for one of his patients. It was an elderly woman with a history of two previous strokes, left-sided weakness, confusion, memory impairment and deterioration in functioning. Her daughter had accompanied her to one of the clinics in the hospital. She was neatly dressed, she walked hesitantly keeping her head down. I proceeded with a Creole version of the Mini Mental Status Examination. It didn't work out. She was totally disoriented. She didn't know her age. Was it profound dementia or total ignorance? Her daughter later explained that she never had a birth certificate. Her family has estimated her approximate age at 63, based on who the president was when she was a child. She looked like she was in her late 70's to me. She looked sad, scared, and emotionally deprived. She spoke with a soft voice and barely looked me in the eye. She was both depressed and cognitively impaired. What would be the most realistic approach with this patient? She can't afford a dementia work-up. She would not be financially capable to afford any medicine for one month, one year, or for the rest of her life. I decided to focus on the activities of daily living. I provided her daughter some tips on assuring her mother's safety and preventing further acceleration of her memory loss. We discussed nutrition, visual cues, and the avoidance of physical change in her mother's living environment. I thought, "Wouldn't it be great to have a local program that would address the mental and physical needs of the elderly?" I couldn't stop thinking about her that night.

Rachel, April and I realized the dedication showed by the volunteer translators. We decided to give them basic training in counseling. We introduced the concepts of listening, validating, empathic reflection, and support to them. Although we didn't inquire about their personal history, we were impressed by their strong will to help others, and by their eagerness to use the tools they had learned from us whenever they had a chance. I thought, " Wouldn't it be cost effective to train other young Haitian volunteers in basic counseling skills and use their services to reach out to people in need of mental health services in the community?"

They talked about their family history, their past successes and failures. With no language barrier in the way, they were eager to state that they were not just the crushed-leg-hopeless-bedridden-amputee who was lying in a tent in Milot. They had a life on the streets of Port-au-Prince. Some have been desperately poor and have lived in shacks; others have had a job, a personal business, a family, and a home. They used to be happy to go about their daily activities, no matter what. Now, they have to rely on others' help for everything. I listened, exploring their feelings about their deceased. I reviewed any previous experience they have had with loss and grief. For each patient, I look for the coping skill that worked for that person in the past. My goal was to help them discover the inner strength that they needed to cope with their terrible emotional pain. Lots of people were just numb.

I did a lot of grief counseling sessions. It was not just about death. Many were afflicted by the loss of their homes, schools, and businesses. Almost all were grieving a severed part of themselves. Some have had a limb amputated, while others have had both removed. One beautiful 12 year-old girl had half of her foot amputated. She also became an orphan. I worked each person thru the stages of loss, counseling them about coping mechanisms and taught them the warning signs of depression, panic disorder and post traumatic stress disorder. I reviewed the concepts of family and social support. I thought, "What will happen to each one of these people one, three, five years from now? Wouldn't it be a good idea to keep track of each one of them, to provide them the support they certainly deserve? I wished I could refer them for mental health follow-up service, once they were to be discharged.

Also, most of these people did not have a history of psychological problems prior to the earthquake, and they were a group in transition. There were many earthquake victim patients on Amitryptyline or Gabapentin. They needed these medicines for nerve pain associated with anxiety and insomnia. For these, I added "provide at least a 90-day supply at discharge." It was more difficult to decide about the use of a selective serotonin reuptake inhibitor to treat depression and anxiety. The supply of these medications for a patient with depression should be at least a two- to three-months supply. Even more would be needed for patients with post traumatic stress disorder symptoms. This raised several questions in my mind: Will the patients get discharged with the supply needed to achieve treatment? What about follow-ups? Will the subsequent treatment be free, too? What positive difference was achievable with the short-term use of an antidepressant unless there was a serious plan for psychiatric care follow-up?

He was lying in the surgical bed with his right leg in traction and his left leg in external fixation when I interviewed him. He was a hard-working citizen before the earthquake. He made wood furniture and also worked as a security guard. He owned a home in Port-au-Prince. His children were doing well in school. His life has totally changed since the earthquake. His house fell like a pancake. The children’s schools collapsed. Three of his kids were relocated to the rural countryside with their grandmother. The other two were staying with his wife at a friend's house. He has not been able to get in touch with them. His major problem was the disruption of his family unit. He said that he had become very depressed. He felt useless because he was unable to fulfill his role as family provider. He felt he would rather die than staying alive and being useless. Many questions arose from this chat. Should I start an antidepressant? Which one was available? How much of a supply was available? If he had to start taking an antidepressant, how will he continue to obtain the medicine? Will he be motivated to take a daily pill when he may not have a daily meal? What about follow-up care? Since I would be leaving in two days, I opted to prescribe daily, brief cognitive behavior therapy. He responded. The tears stopped. I thought, "Wouldn't it be great to have a social worker service available? It will help these displaced people to reunite with their families."

My goal today was to assess who was at risk of decompensation and who wasn't. I found out that although most people were strong, many may be numb. All the patients I have examined have suffered from acute stress disorder. All were dealing with loss, grief, situational depression, or adjustment disorder. Some were experiencing mood disorder secondary to their medical condition. Many were subjected to re-experiencing, nightmares, avoidance, anxiety, numbing, and hyper arousal. Few were ready for a new start. But no patient I have evaluated in Milot was actively suicidal, homicidal or psychotic, at least during the time I was there. They had outlived the earthquake. They were saying that they needed to pull through misery, isolation, physical and emotional pain. They inquired about established mental health centers where they would continue to receive the help they will need for so long. They expressed their fear that primary care doctors, nurses, teachers, and neighbors will not understand their emotional symptoms and will not address them accordingly. They all had come to the understanding that their need for psychosocial intervention was not for a week or two but for months and years to come. For the most part, they were resilient. Everyone believed firmly that God will make them a personal miracle, that someone will help them out of the dire situation. I thought, "Spiritual counseling is a very important tool in the Haitian day-to-day survival. Empowerment will help too."

The therapists Vivian, Rachel, and April have been working hard, too. Day after day, they sat at the patient's bedside. They have used short trauma-focused therapy sessions and relaxation techniques. Vivian practiced the Eye Movement Desensitization and Reprocessing (EMDR). I sat with her as a translator once. The patient was a woman in her 20s who was experiencing intense feelings of guilt, flashbacks, and recurring ruminations. Her young cousin, who visited her the day of the earthquake, was leaving the patient's house when the earthquake hit and a church had collapsed on her. The patient felt that if her cousin had not visited her that day, she would still be alive. Vivian started an EMDR session with her. She proceeded several times and it worked for this woman. I thought, "Wouldn't it be helpful to hold neighborhood mental health fairs all through Haiti? After all, everyone in Haiti had suffered trauma on a different scale."

While on the way to New York, I couldn't stop reflecting about the children who were begging on the streets of Haiti. They were desperate for help. Missionaries and visitors were charitable to them. I kept on wondering if this act was a helpful one or was reinforcement for negative behavior. As a child psychiatrist, I felt extremely conflicted. I have known that any positively reinforced negative behavior demonstrated in childhood could lead to problems in adulthood if not addressed early. Erickson's Stages of Development theory kept running through my mind. I thought, "If attending school was mandatory for all children in Haiti, if a free hot meal was served at all elementary and secondary school, would kids be begging on the streets?"

The thought that Rachel, April, and I have just planted the seeds for a "Counseling 101"in Milot just kept coming back to me. It had started almost spontaneously. The idea was triggered by the interest demonstrated by the volunteers and by our desire for a continuum. We promised to keep them updated by sending them basic counseling training books, articles, and website addresses that would help them learn more. I am hopeful that this initiative will spread to reach other people. Haiti needs to have everyone involved, from professionals as well as lay people. I thought, "If each one of the missionaries who went to Haiti had trained one or two people in their field of expertise, Haiti would have benefitted from a non-perishable deed."

I’ve always wanted to be involved in international health. Teaming up with an interdisciplinary group of health care workers has made my first experience fruitful. Each night, after dinner, we gathered to share our experiences from the day. We were all specialists in our designated fields, yet humble and open to learning more. I witnessed the surgical team’s satisfaction after they created an anus where none had existed for an 11-year-old boy who had been relying on a colostomy bag to perform a function most of us take for granted. Others talked about their efforts at treating typhoid or malaria. The positive outcomes in mental health interventions were not as immediate for me, making my experience different from theirs. The results of my interventions were not as predictable. The profound lack of basic psychosocial interventions in Haiti makes a psychiatrist’s work more difficult and, sometimes seemingly fruitless. Mental health has long been a taboo in Haiti and still is. Psychotherapy, psycho education, family reunification, community empowerment, and provision of strong social support should be the first steps in addressing the mental health of Haiti’s earthquake victims. For the time-being, psychiatrists in Haiti would be better able to overcome the taboo if they were willing to play a major role as trainers or as consultants for the primary care providers. I thought, "Only a collaborative effort in healthcare delivery in Haiti will address the multi-faceted problems that the earthquake victims still face."

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