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Sunday, August 2, 2015

So Much Trauma, So Close to Home: Seeing Beyond the Bidonvilles to Celebrate Porosity in Port-au-Prince

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: 

  1. 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.

  1. URAMEL for their broad NGO-style mandate to work with medico-legal issues but also a wider vision that includes mental health.

  1. Mission Sociale des Églises/Pastoral Social Mission – community-based and outreach-focused interfaith group with a mission and a vision.

  1. 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.

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