Haitians will need extraordinary help in dealing with the psychological aftereffects of the January 12 earthquake and reconstructing its meager mental health system, but any such assistance will demand a sensitivity to Haitian culture and history to avoid making a catastrophe worse.
For a start, a mere willingness to help the devastated country is not enough.
"People who go there now need real experience in disasters, in part because of the insecurity surrounding anyone who goes in to work," said Kenneth Thompson, M.D., medical director of the Center for Mental Health Services in the Substance Abuse and Mental Health Services Administration (SAMHSA), in an interview.
"It is hard to get help for Haitians but also hard for people who want to help to get the resources to be helpful," he said.
Haiti's mental health system was in rocky shape even before the earthquake. A 2005 World Health Organization Atlas found no available information on mental health financing or facilities in Haiti and no data on the numbers of psychiatrists, psychologists, social workers, or related professionals working in the country.
The main psychiatric hospital in Port-au-Prince was destroyed in the earthquake. Built for no more than 40 patients, it actually held more than 80, in poor living conditions, said Haitian-American psychiatrist Jean Tropnas, M.D., founding president of the Haitian-American Psychiatric Association (HAPA) and a clinical professor of psychiatry at Downstate Medical Center in Brooklyn, N.Y. Tropnas has no idea what happened to the patients or to those in a second hospital in Beudet.
HAPA is now consulting with New York University to provide Haitian-born psychiatrists interested in returning to the island with training in disaster mental health.
"It is an immense tragedy, but Haitians had been traumatized for a long time," said Tropnas. "They have faced multiple other disasters—floods, hurricanes, political disasters, tortures. At the start of the AIDS epidemic, they were blamed for spreading the virus."
The pain has deep roots, said Tropnas. Haiti was neglected and isolated after winning its freedom from France in 1804, and was burdened with reparation payments to France for more than a century, draining it of capital that might have built the country.
"Haitians have been depressed and exhausted by other disasters in life," he said. "Any psychiatrist intervening there will have to be ready to hear that fatigue and depression. The apparent stoicism leads to a certain mistrust, making Haitians resistant to opening up. I feel that as we approach these folks to try to help them, we have to be very sensitive to what each person is carrying with him or her—history, culture, pain."
"Any program that seeks to help people in the country will have to take into account the Haitian mentality," agreed Haitian-born Marie-Claude Rigaud, M.D., M.P.H., an occupational psychiatrist in Aurora, Ill.
Haitians have exhibited great resilience in the face of adversity—they've had plenty of practice—but there is also an element of denial in their response to hardship, said Rigaud.
"They will say they are O.K. when they're not, so as not to look weak," she said. "Some Haitians also have difficulty functioning in groups, and a spirit of rivalry and competitiveness often can destroy group cohesion."
Bringing outside mental health assistance to Haiti presents a number of difficulties beyond cultural sensitivity. For instance, its language, Creole, is derived from French, but pronunciation and spelling are different enough from the parent language that additional training is required to work in it, even for people who have studied French.
SAMHSA organized, with the help of APA, a program to send psychiatrists and other mental health professionals to Louisiana, Mississippi, and other affected areas to help after Hurricane Katrina in 2005. A similar program is unlikely to happen quickly for Haiti.
The primary reason is that Haiti is a sovereign foreign country. Any aid must be requested officially by the Haitian government through the U.S. Department of State. Then that department must officially invite the Department of Health and Human Services, SAMHSA's parent agency, to take part.
"If and when the Department of State asks for our help, we will involve the Haitian government in all phases of planning and operations," said Winnie Mitchell, M.P.A., international officer at SAMHSA.
SAMSHA's approach will likely be similar to the one it used to help build mental health capacity in Afghanistan.
"We will consult with the Haitian government and Haitians living in the U.S. to understand the country's needs, then delegate a working group to meet regularly and quietly to provide technical and emotional support," said Mitchell in an interview. "However, we don't know when we will start."
The agonies don't end at the island nation's shores. Haitian Americans and Haitians living in the United States have lost relatives and friends. Many have simply not been heard from since the quake. While they are probably dead, the lack of certainty doubles the pain.
Brooklyn has the largest concentration of Haitians in the diaspora, said Tropnas. He and his colleagues were already using community outreach techniques there in neighborhoods, at health fairs, and on the radio to educate people and screen for mental health issues.
Since the quake, a van from Downstate Medical Center drives through the streets, offering mental health information to residents. Discussion about trauma, PTSD, grief, and acute stress syndrome has intensified on the radio program. Medical students, residents, and attending physicians from Downstate also go into local businesses simply to chat and remind people that help is available.
Ten days after the quake, following Mass in Creole at St. Jerome church, Tropnas and his team set up shop with primary care providers in the church basement and saw about 40 parishioners with a variety of complaints.
"Some just needed to talk, but some needed medications for acute symptoms," said Tropnas. "We plan to continue as long as it will take."
The Haitian American Mental Health Center, part of the Cambridge Health Alliance (CHA) in Massachusetts, has seen similar fallout from the quake.
Patients and many staff members have lost relatives and friends, said clinic director Mel Schmid, L.I.C.S.W., who spent 16 years working in Haiti at a now-destroyed seminary and is fluent in Creole.
Watching televised scenes of Haiti after the earthquake, people were overwhelmed with shock and disbelief, said Schmid. National symbols like the presidential palace were destroyed. Helplessness reigned. They were unable to return to Haiti to help in person and couldn't even wire money because the banking system was out of commission.
Haitian Americans who had spent years working in the United States, saving money and sending it home to invest in houses and businesses that were largely uninsured, saw their life savings literally crumble.
They were also unable to provide proper care or mourning for the dead—an important part of Haitian culture.
"There was a slow realization that all the familiar things about the cities and towns they knew—the buildings, the streets, the stores—were gone," said Schmid.
CHA staff members have found several ways to help people cope. Some want to talk with family and friends, some to volunteer in some way "to feel like you're doing something."
"We try to be less focused on information and get them away from the television."
Because it doesn't require diplomatic formalities to act within the United States, SAMHSA can provide technical assistance—like translating consumer materials into French and Creole—to state disaster mental health coordinators in states with large populations of Haitian Americans. It will also provide support for personnel responding domestically to the crisis as part of the National Disaster Medical System, the commissioned corps of the Public Health Service, and others.
APA plans to convene groups of psychiatrists working in areas with large Haitian-American populations, work with disaster liaisons in affected district branches, and serve as a clearinghouse for information, according to Annelle Primm, M.D., M.P.H., director of APA's Office of Minority and National Affairs.
In the United States or Haiti, the need for help will exist well into the future.
"Mental health issues in Haiti will snowball for years," said Thompson. "There will be more and more hurts in their lives as long as they live."