On January 12, 2010, a magnitude 7.0 earthquake devastated the Haitian capital of Port-au-Prince and left over 200,000 people dead. The subsequent outpouring of sympathy and aid from the international community, while valuable and heartfelt, was long overdue. One cannot get a sense of the challenges that face post-earthquake Haiti without having a sense of the problems that existed long before the disaster. In this article, I attempt to give context to the challenges and adversities in post-earthquake Haiti by sharing my personal experiences living and working in Haiti before the earthquake.
I went to Haiti to work at a Haitian-run HIV/AIDS clinic in downtown Port-au-Prince. This clinic was the first institution in the world dedicated to the fight against HIV/AIDS; it began caring for patients in 1982 and has never shut its doors or charged for care. I arrived in July, 2004, 5 months after former-President Aristide was ousted and 7 months after the Haitian people celebrated their 200th anniversary as the first independent nation in Latin America and the first black-led republic in the world. Sadly, the celebrations were short-lived. The political upheaval that sparked Aristide's exile lingered, despite the presence of the United Nations Stabilization Mission in Haiti (MINUSTAH). Chaos continued to escalate, igniting violent surges marked by gang rapes, kidnapping, and torture (1–4).
In its over 200-year history, with 33 coups d′états, (5) Haiti has been plagued with corruption, political instability, and violence (6, 7). Roaring poverty, the easy availability of illegal weapons, and an underfunded, undermanned, and often corrupt police force have all combined to make violent crime a constant danger. The following events exemplify the kind of dangers that all Haitians have faced.
One of the most endearing individuals I have known was my landlady. She was raised in Haiti and educated in France, and, by the time I met her, when she was in her early 60s, she had raised three children, had two marriages, and could boast of a successful career as a competitive ballroom dancer. In Haiti, she juggled many jobs: landlady, educator, and dance instructor, and she managed logistics for the French Embassy, including being responsible for the embassy vehicles. One day, a fellow embassy employee informed her that he was going to borrow an SUV to drive to the airport. She warned him that the direct route to the airport, which cut almost an hour off the commute, went through a dangerous area of Port-au-Prince and was off-limits to embassy personnel. Before dawn the next morning, she received a call; her colleague had never arrived at the airport. He had taken the shorter route and had been shot and killed. Two United Nations tanks and a tow-truck were sent to the area to retrieve the vehicle and his body. A close colleague I will henceforth refer to as Justine had recently finished medical school when she began working at the HIV/AIDS clinic. She was an attractive young woman from an upper-class Haitian family, which her lighter skin betrayed. We became friends and collaborated on several projects. She and her younger brother lived in a large house in a wooded area of Port-au-Prince; one of the only remaining forested areas in the city. The land was bought in the early 1900s as a preservation site. Those who built homes in the area were forbidden to build walls, and any trees cut down had to be replaced. Her home had no surrounding wall when it was first built. After the second robbery and a terrifying encounter for a family member in the house at that time, the family erected a nine-foot wall and hired a guard to patrol the gate. Justine's mother had moved to the United States and wanted Justine and her brother to join her there, but Justine wanted to continue her work at the clinic, and her brother, a very talented jazz pianist, wanted to stay in Port-au-Prince's thriving music scene. One evening after work, Justine and I were at her house working on a research project when she got a phone call. After spending several minutes trying to understand who was on the other line, she began pacing back and forth saying, “Non! Ce n'est pas possible! Ce n'est pas possible!” It was the police informing her that her brother had been shot. It was not clear whether he was still alive, and we spent the next several hours driving around town looking for him. We drove by the hospitals and the morgue, where bodies had been piled one on top of the other and the floor was covered in blood. Most of the bodies were young men, like her brother, who had died traumatic deaths. Finally, her phone rang; it was her brother's girlfriend. She had been driving with Justine's brother in the lower Delmas area when they were flagged down by several men. The men walked up to the car and fired one shot that struck him in his head. Her brother opened the car door, slumped to the ground, and died. These stories reflect the difficulty Haiti faces in policing its cities. The Haitian National Police (PNH), created in 1995 to replace the dismantled Haitian Armed Forces, was the first civilian police force in Haitian history. Before the earthquake, the PNH had approximately 4,000 officers serving a population of 8.3 million people (8) and contending with an estimated 210,000 handguns in circulation throughout the country (9). In contrast, the Dominican Republic (east of Haiti, on the island of Hispaniola) had a population of 9 million, a military force of 44,000, and a police force of 32,000 (10). In New York City, 8.1 million people (11) had ten-fold the number of police as did Haiti (12, 13).
Rape had already reached crisis proportions in Haiti before the earthquake. Years of political instability, lack of a functional police force, and a weak judiciary system created an environment conducive to the perpetuation of violence. The dearth of effective deterrence left many resigned and defeated, a trend perhaps most sadly illustrated by the plight of the “rest-avec.”
A middle-aged man and his son owned the house in which my landlady and I lived. They resided on the top floor, and two teen-aged sisters lived in the servant's quarters behind the house. Their parents had died many years earlier, and they worked for the owners as rest-avecs, a job whose duties include cooking, cleaning, and performing sexual favors. The term “rest-avec” roughly translates to “stay-with” and refers to a young child, either sent by their parents or orphaned at a young age, who is taken into the home of a wealthier individual or relative. They are provided food and shelter in exchange for labor and, often, sexual services. A rest-avec, who lies at the bottom of the Haitian social hierarchy, could scarcely imagine accusing anyone of rape. Since April 2000, the HIV/AIDS clinic provided psychological and medical services for survivors of rape. Services included emergency contraception, prevention and treatment of sexually-transmitted infections, HIV-testing, post-exposure antiretroviral prophylaxis, and long-term psychological counseling.
A close friend I will call Sophie worked as one of the psychologists at the clinic. The daughter of a Colombian mother and a Haitian father, she was a tiny, lighter-skinned woman in her late 20s, with long, dark, curly hair and a soothing manner that put people immediately at ease. Sophie provided psychological support to survivors of rape. She had studied psychology in France only to discover that Freudian psychoanalysis was less useful in this environment. She would always introduce herself to patients by saying, “I'm a psychologist. Do you know what I do?” Few patients ever did. She would discuss the availability of individual counseling and the option to join a support group, but most women declined both offers. They had come for the medical interventions. I once asked Sophie why patients refused to return, and she explained with the following example: A 16-year-old girl had come in for treatment that day. Four unknown men had broken into their home, stolen anything of value, beaten her father, and raped her and her mother. Now, she had to take care of her little sister, who had also been raped, and she had to continue her full-time job to help support her family, bring food to the table, and pay for her schooling. She had no time for counseling. After the February 2004 ouster of the former president, the clinic provided care for approximately 31 victims of sexual violence each month, a striking increase over the 4 patients per month seen before that time. By the summer of 2005, Sophie noticed more parents bringing their young daughters to the clinic. These girls had been raped by assailants known to the family, usually a neighbor. A year later, the number of victims per month had risen to almost 50, with a higher proportion of girls under the age of 16. The situation slowly stabilized over the course of many years, but, in the aftermath of the earthquake, gender-based violence is once again on the rise (14). A recent report by Refugees International documented the continued rise in gender-based violence 10 months after the earthquake (15). I was in my third year of a psychiatry residency when the earthquake struck, and, not long after, I received an e-mail from another colleague and dear friend, who informed me that my landlady had died. “She was working at Cercle Bellevue when the earthquake hit. According to [her daughter], they haven't even been able to recover her remains.”
Justine continues to work at the clinic, and her courage and strength exemplify what life often demands of people in Haiti. Sophie is living in Port-au-Prince, working for a non-governmental organization counseling rape survivors, and fighting to improve the lives of women. My dear friend and colleague, a young Haitian man in his early 40s, came to the U.S. to study. He completed both M.D. and Ph.D. degrees at the Albert Einstein School of Medicine, a residency in internal medicine, and a fellowship in infectious disease at the Weill Cornell Medical College. After his studies, he moved back to Haiti to work at the HIV/AIDS clinic, where he continues to work. He recently established a cholera treatment center, and I know he will play a critical role in rebuilding Haiti.
Psychiatric training has taught me the importance of listening—to my patients, to my emotions, and to the exchange that takes place between me and those around me. Haiti has been in dialogue with the rest of the world for over 200 years, but few have been listening. When I consider how my experience living in Haiti influenced my growth as a psychiatric trainee, I reflect upon the value of trust, which I have learned can only be gained over time and through listening. Psychiatric patients frequently experience tremendous suffering, often exacerbated by a lack of social support. I have come to recognize that my patients will only seek my support in a setting of trust, without which my support becomes greatly diminished. The same may be said of Haiti. Although support from the international community has been valuable, the suffering of Haitians began long before the earthquake. We may want to reflect on our own motivations and on what we may gain from supporting others. Earning the trust of another may be the greatest form of support, and, two years after the tragedy, I believe we have yet to gain the trust of Haiti. In the midst of incomprehensible loss, I remain hopeful about Haiti's future because of the efforts of those who continue to listen and because of the spirit of the Haitian people, who will rise from the rubble to rebuild a stronger, more capable, and independent Haiti. I often hear them say, “Men anpil, shay pa lou,” which means “With many hands, the burden is not heavy.”