Newsletter
of the Global Mental Health &
Psychiatry Caucus
of
the American Psychiatric Association
Vincenzo Di Nicola, MPhil, MD, PhD, FRCPC,
FAPA
Professor
of Psychiatry, University of Montreal
Representative
to the APA Assembly
Past-President
of the Quebec & Eastern Canada District Branch
Newsletter
Zonal Co-Editor for the Americas
AS
A LIFE-LONG STUDENT of trauma and as a francophone psychiatrist working in
Montreal, a sojourn in Haiti’s devastated capital, Port-au-Prince, beckoned me
for many years. Whenever I asked a Haitian colleague about visiting Haiti, he
would say, wait for things to settle down. First it was due to politics,
following the ouster of President Aristide in 2004, later it was the
devastation in the wake of the earthquake that fairly leveled the capital city
in 2010.
Almost
no one encouraged such a visit! Neither Haitians themselves, nor my colleagues
in health care supported it. Their message conveyed a perfect storm of
devastation, destitution and danger. Those who survived the earthquake and
those who worked there in its aftermath transmitted lessons about
“trauma”—traumatic events (poverty, violence, disasters), a traumatized
population in survival mode, and traumatizing experiences (alienating
experiences on the streets and with the health care system). Finally, with
support from three sources – the University of Montreal’s Department of
Psychiatry, APA’s Global Mental Health & Psychiatry Caucus, and the Harvard
Program for Refugee Trauma – I was on my way.
When
the Global Mental Health Caucus meeting was held at the APA Annual Meeting in
Toronto this year, I spoke to the disabling notion that we come to other places
as experts with knowledge and skills, diagnoses and solutions. On the eve of my
first visit to Haiti, I set myself the challenge to learn from my hosts and my
encounters with Haitians.
So,
what did I learn during my Haitian sojourn?
“LA
KAY SE LA KAY.” First, it would be foolish to deny the problems that are
evident everywhere in Haiti. To adapt the title of Raymond Carver’s short
stories, in Haiti there is so much
trauma, so close to home. And yet, I believe that as psychiatrists, we see
trauma after the fact, like an ambulance arriving after the accident. It’s a
crucial point: we often see effects and consequences, not the trauma itself. We
do not have direct access to the human experience that we call trauma. And
these impacts are not always traumatizing, which I understand to mean limiting
or disabling. In Port-au-Prince, signs of physical disaster are more evident
than signs of disabling human trauma. While the walls of the city declare in
Creole, LA VI PA FACIL, Life Isn’t Easy,
they also affirm that, LA KAY SE LA KAY,
Home Sweet Home.
“This
Too Shall Pass!”
Second, there is the question of state structures, resources and solutions. In
geopolitical circles, the concepts of failed states, collapsed states and
fragile states have been floated. Do they apply to Haiti? Well, it depends.
While I prefer the nuances of fragility
rather than failure, it depends on
whether the concept applies strictly to a state’s sovereignty or to the people.
If it’s true that the state has failed or is fragile, it’s equally important to
witness that the people have not! One of my hosts taught me a Haitian saying, “CAP—Cela aussi passera!” This too shall
pass! Several of my Haitian hosts understand this attitude not as fatalistic
but as pragmatic resignation. What would trigger a strike in the neighboring
Dominican Republic, over bus fares, for example, is met with weary resignation
by Haitians, according to my Haitian host, psychiatrist Dr. Hans Lamarre,
President-Elect of our APA District Branch in Quebec and Eastern Canada. Haitians
are at once both resigned and guardedly hopeful!
A
palpable spirituality pervades the entire public experience of Port-au-Prince!
I asked this question many times: Did the earthquake change the people’s faith?
The unanimous answer, declared on the buses and walls of the city with such
affirmations as—DIEU TOUT PUISSANCE, All Power Is God’s, and BON DIEU AVANT TOUT, God Is Good, Above
All—is that disasters fortify rather than shake the people’s faith.
Porosity. Finally, my visits to other places
helped me see beyond half-destroyed, half-rebuilt buildings, to witness
material poverty abutting cultural richness. I avoided the “disaster tourism”
that I experienced in Rio de Janeiro, New Orleans, and Buenos Aires. Ghettos, favelas, bidonvilles—whatever
we call them, from Portugal’s barrios de
lata (shanty towns) to the ciudades perdidas (lost cities) of
Mexico, slums dot the world, residing
within, on top of, beside or below the world’s major cities.
Port-au-Prince,
in mountainous Haiti, is one big Rio de Janeiro with bidonvilles clinging precariously to the mountains while the
government buildings, hospitals, schools and churches that still stand after
the 2010 earthquake crowd the city’s plateau. But it is also a Caribbean
Naples. Walter Benjamin’s essay on Naples captured its most abundant quality—porosity. And like Naples,
Port-au-Prince is porous, incomplete, unfinished, with boundaries and
categories bleeding into each other, overflowing with jarring juxtapositions:
funky art galleries beside “Gingerbread” ruins, street slogans and banners in
the people’s Créole amid a panoply of
ads for private schools in proudly refined colonial French, symbols of African Vaudoun that we know as “Voodoo,”
intermingled with French Catholicism, and everything for sale on the streets in
a city suffused with spirituality. Port-au-Prince is vulgar and refined, sacred
and profane, impoverished and privileged—much as Naples, New Orleans, and
Salvador, Bahia, port cities of the world where the culture rises from the sea
and the ground up.
In
sum, as a cultural psychiatrist, I observe everywhere that the work of culture—dialogues
and relations, knowledge and solutions—is acquired and constructed, not merely
hard-wired. This was magnificently manifest during my sojourn among Haitians
through the beauty of their poetry, their art and sculpture, their adaptability,
and their unshakeable faith. And the Creole art of living porously is what will
bring me back to learn more about the culture of Ayiti, Haiti.
Haiti Mission Report and Strategic
Plan
In the spirit of the above carnet de
voyage or travel diary, here is a partial list of activities, contacts and
projects during my first mission in Haiti in May of 2015:
· Inaugural lectures on child
psychiatry at the Faculté de Médecine et
des Sciences de la Santé, Université Notre Dame d'Haïti (FMSS-UNDH),
supported by the Dean, Dr. Jean Hugues Henrys, and the Vice-Dean for Teaching,
Dr. Audie Metayer, of FMSS-UNDH. These were the first lectures on children’s
mental health needs in Haiti. Furthermore, there are no child psychiatrists in
Haiti and no child psychiatry services there.
· Visit to the Mars and Kline
Psychiatric Hospital, Port-au-Prince, where I participated with Dr. Hans
Lamarre in a clinical seminar with psychiatry residents and medical students.
· Colloquium at URAMEL - Unité
de Recherche et d'Action Médico Légale – Fondation de France/Unit for
Research and Forensic Action, Port-au-Prince, on “Our Youth at Risk,” attended
by psychiatry residents, psychologists and a variety of local health care
professionals and medical leaders.
· Meeting with psychiatric and business leaders, Dr. Claude
Manigat and Mr. Oswald Brun, who have recently founded the Fondation Haïtienne de la Santé Mentale/Haitian Foundation for
Mental Health. I offered to work with them concerning youth and families in Haiti.
· Meeting with Pastor Clément Joseph's interfaith group – Mission Sociale des Églises/Pastoral
Social Mission – to help them build a plan for psychosocial support in the wake
of disasters, natural and man-made. Pastor Joseph is a strong leader with
charisma, an ecumenical mission and an established community resource base. We
have reached out to Dr. Eliot Sorel, the Chair of the Global Mental Health
& Psychiatry Caucus, and U.S. Gen. Russell Honoré, a distinguished leader
in the field of disaster planning, both of whom have offered their assistance
to this group. Pastor Joseph invited me to work with two groups – the
interfaith coalition and a group of 25 pastors to sensitize them on children
and family issues.
· Meeting with Haitian psychologists who are foreign-trained
(France and Belgium) and in private practice seeking training, supervision and
support in couples and family therapy. They could be the founding group for Haitian marital and family
therapy with our support. They plan to bring me back to Haiti for advanced
training, supervision and professional support.
There are too few
psychiatrists and no child psychiatrists in Haiti, a country of an estimated
population of 9.446 million people in 2006. A WHO study published in 2011 identified
27 psychiatrists there, but the leaders I met informed me that the number is
perhaps only half of that! More critical than the limited human resources is
the “treatment gap” in children’s mental health care. Even where there are
epidemiological studies that establish the prevalence of identifiable mental
health challenges, significant treatment gaps exist between those challenges
and access to care, including in much better resourced nations such as the USA!
In the light of these observations, I want to identify people
who are already working with youth, families, and communities in order to find
local partners for my mission. I believe we can identify four distinct
groups:
- FMSS-UNDH
for preparing future physicians and planting seeds. Dr. Richard Mollica,
Director of the Harvard Program for Refugee Trauma (HPRT), has been
working with Fr. Jean-Charles Wismick, Ph.D., Vice-Rector for Academic and
Scientific Affairs at UNDH, to establish a mental health program with both
teaching and clinical components.
- URAMEL for their
broad NGO-style mandate to work with medico-legal issues but also a wider
vision that includes mental health.
- Mission Sociale des Églises/Pastoral
Social Mission – community-based and outreach-focused interfaith group
with a mission and a vision.
- High-level
professionals with training and experience at international standards who
are in private practice and who serve a certain class while taking part in
planning and support to other organisms with a broader reach; my hope is
that supporting this group will establish new ideas and practices in Haiti,
that eventually, through “trickle-down” and “tracking-through,” will
benefit more of Haitian society.
In short, the local and
national human resources in Haiti are solid, creative and inspiring! They have
the leadership, drive and task-orientation that is needed for building a better
society. My own limited mission is part of a larger one that involves colleagues
in pediatrics and will soon include obstetrics-gynecology and surgery.
Our mission in global mental
health involves Dr. Hans Lamarre, Haiti Mission Director, and Dr. Emmanuel
Stip, Chair of the Dept. of Psychiatry at the Université de Montréal/University of Montreal, working closely with
Fr. Wismick at the UNDH and Dr. Mollica at the HPRT, and the support of Dr.
Sorel, Chair of the APA GMH&P Caucus. Together, we are participating in a historic
opportunity to build sustainable programs for integrated, total health of
children, families, and communities in Haiti.
