Smith Altema was in class waiting for an exam to start, when he decided to step out to take a short bathroom break. Moments later he could feel the ground moving under his feet. When he looked to where he had been only minutes before, he saw the school building flattened, with his classmates and professor still inside. That day he and other survivors found an empty field near the school to stay overnight as they waited for the aftershocks to pass.
“It was a horrible experience for me,” Altema said. “The images you saw, the dead bodies…it was a lot.” On top of dealing with the trauma from the quake, Altema also lost his girlfriend of seven years in the earthquake.
“This was one of the worst things that could have happened to me in my life,” he said. “This was an experience that marked our souls and would stay with us forever.”
When the earthquake hit Haiti, Jean Pierre-Louis’ nonprofit Capracare was less than a year old. He and his team had already planned to travel to Haiti for a professional development retreat for the organization’s community health workers, but changed their focus after news of the quake fell.
“We had to change the whole mission of the trip and change our agenda to mental health,” Pierre-Louis, president and CEO of Capracare said. The nonprofit founded in 2009 develops sustainable community health programs for children and their families living in Haiti.
“I knew [mental health] was a topic that was heavily ignored.”
Pierre-Louis had tried in the past to work with the Haitian community on mental health wellness, however, the reception was less than favorable.
“My grandmother’s first six children died, and I thought, wow, what kind of support did she have?” he said. “I’m imagining how do you lose six kids, without having a mental breakdown, and there were no mental health services available.”
So he began to survey others in the community to find out whether it was common for Haitians to face such severe stress without professional help, and to gauge whether they would be receptive to services.
“Everyone would say, ‘oh no, it’s ok. We don’t need that type of support’ because they didn’t truly understand what mental health is,” he says. “It ended up not being a big focus area because they were relying on support from family, from the community, from church.
“But, when the Haiti earthquake happened, then the light bulb went off — ‘I’m not crazy. This is serious.’ That’s what triggered us to go back to that same community to provide psychological first aid.”
They were in Haiti within three weeks of the earthquake. Shortly after, they were introduced to Altema.
He had a difficult time talking about his experiences with the earthquake.
“At first, I didn’t want to talk about what happened,” he said. “It hurt me a lot to speak about it.”
However, after he came across Pierre-Louis and his team of mental health specialists, he started to open up to the idea of speaking to a psychologist — something he thought was reserved only for moun fou (crazy people).
“Before the earthquake, I thought mental health was about treating people who had problems in their head…crazy people,” he said. “That was my perception.”
Ten years later, his view of mental health had turned on its head.
“I understand it more now,” Altema, who’s now a doctor and runs CapraCare’s Haiti medical division, said. “Mental health isn’t [only] about people who have a mental illness or are considered crazy. Mental health [services] are here for everyone in general. Regardless of who you are, you need mental health [services.]
“It’s very important. Everywhere should have a psychologist,” he said. “In schools, in churches…everywhere.”
There are few success stories reported on when it comes to Haiti. Stories about fraud, mismanagement and suffering are commonplace, and most have become accustomed to the Shakespearean nature of Haiti’s history and current condition. However, when it comes to mental health, the devastation Haitians faced on Jan. 12, 2010 helped shape a success story that few would have anticipated from the small country.
“Around the earthquake there was a lot of activity around mental health. Mental health is an area of global health development that is severely underfunded,” said Giuseppe Raviola, an assistant professor of psychiatry at Harvard University. Raviola works with Partners In Health (PIH) –Zanmi Lasante as it’s known in Haiti — and the Haitian Ministry of Health to develop a scalable model for community mental health in Haiti.
“The resources tend not to exist for community mental health in much of the world. What can happen in disasters like the Haiti earthquake, is that there’s a short-term interest, but then that interest fades.”
However in Haiti’s case, the overwhelming need for mental health services in the wake of the earthquake exposed a need that many in the country thought they could do without.
Raviola and his partners at PIH were asked by Dr. Alex Larsen, the minister of health at the time, to help address the lack of mental health services in the country for the long term.
“He acknowledged that mental health has been neglected, and he said given the history of Zanmi Lasante in the country, there was a foundation of trust on which a mental health system could be developed.”
Addressing mental health in developing countries is a challenge for a number of reasons.
First, like in countries all over the world, mental health is a taboo topic, with a stigma that there’s something “wrong” with the person seeking care. Secondly, mental health is perceived as a luxury and something for moun blanc (white people). Lastly, mental health issues are rarely given priority considering the range of other issues people in developing countries deal with, such as high unemployment, unstable economies, and food insecurity.
In developing countries, the number of mental health workers can be as few as 2 per 100,000 compared to more than 70 in high-income countries, according to a mental health report from the World Health Organization.
Fewer than half of the 139 countries with mental health policies in place have plans that accord with human rights conventions. And all too often, when plans for mental health campaigns or initiatives are made, they are under-funded and under-resourced.
There are two psychiatric hospitals in Haiti, both in Port-au-Prince, making it difficult for those in the countryside to access formal care. On top of that, the conditions of the hospitals are subpar.
“These psychiatric institutions are totally underfunded. They are under-equipped. They are understaffed. That means the quality of service provided in these two institutions is very low, ” said Pere Eddy Eustache, an ordained Catholic priest and psychologist who works with PIH and Raviola. “The health system is not funded by the state. Patients in the hospital have to pay for all of the services because the budget related to the functioning of these institutions does not cover services. It just covers salary. That means patients have to cover everything from supplies, to lab tests, and people coming from remote areas cannot afford these kinds of expenses.”
People from the countryside would prefer to go to traditional healers, like a Wanga (Vodou priest), rather than travel hours to Port-au-Prince for mental health services, Eustache said.
For cultural reasons, Haitians are likely to relate every kind of illness they have that they cannot understand to Vodou, he says.
“For instance, a psychotic crisis may be seen as a case of possession or a curse. This is normal. What’s challenging is when the clinician cannot try, or cannot negotiate the two models — the western model and the traditional model.
“[However], when both models are put together, without trying to get rid of the traditional explanation, patients feel respected in their tradition, in their culture, their value, and the negotiation can go well and the treatment can take place.”
As part of his work with Zanmi Lasante, Eustache and his partners work with traditional healers to serve as a bridge between patients and clinicians.
“[We] try to expose them to the western model, how we call these symptoms, and to listen from there how they address and how they understand these types of situations,” Eustache said.
“Recognizing the cultural aspect was important,” Raviola added.
In 2011, they conducted a qualitative context assessment to understand local perspectives with regard to mental health and mental health care. Community health members, community health workers, Wangas, Mambos (Vodou priestess), Catholic priests, and other health workers were interviewed.
“The participants identified issues related to poverty that were exacerbated by the earthquake, making them all vulnerable to manifestations of sadness, depression, suicide, psycholtic illness,” Raviola said. “The opinion was very consistent, from traditional healers to providers and others, that there was a wide acceptance for the need of mental health care.”
They put together a planning framework for a formal system of care, including a depression screening tool that used local idioms and concepts of distress to describe phenomena like depression in the rural Haitian context. They also hired a full Haitian staff led by Eustache.
“There’s been nine years of experience developing services delivered by Haitians in a collaborative system that includes psychologists, community health workers, physicians, social workers, and nurses,” Raviola said.
“It’s a complex world, with climate change, economic and social disparity. There are real challenges to mental health and that’s a global phenomenon. The services delivered by Zanmi Lasante are appreciated and needed as mental health services just as they are needed everywhere in the world.
“The program has overcome very significant challenges to provide mental health services and is a referral point for the nation.”
As for Pierre-Louis and his team, they set up an operation that would last long after the tremors subsided and the immediate shock wore off. They trained 20 of their staff members on providing psychological first aid, and then travelled to a makeshift hospital in Les Cayes where they provided one-on-one counseling.
Compared to Zanmin Lasante’s more culturally-integrated approach to scaling mental health services nationwide, Pierre-Louis and his team provides “low-threshold counseling” that focuses on healing through building strong interpersonal relationships with patients.
“We thought that while we can provide this service, what’s going to happen after we leave?“ he said. “We spent a good week and half training them and then we were able to start providing service to those who were traumatized.”
Their work in Haiti continues today with ongoing mental health training for staff and a regular flow of patients utilizing their services.
“You have people that were depressed. People who lost family members,” Pierre-Louis said. “There were those who came who had missing fingers, missing limbs. All of that was impactful in changing how people perceived mental care.
“Ten years later, people are more open to [mental health services] now,” he said. “Unlike prior to the earthquake, they understand now, that no, this isn’t just life. It’s an experience that actually impacts me mentally.”