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Address correspondence to Kathleen Molly McShane, University of Miami, Department of Psychiatry (D-29), 1695 NW 9 Ave. #3100, Miami, FL 33136; KMcShane@med.miami.edu (e-mail).
20, 2010; Revised
11, 2010; Revised
11, 2010; Accepted
In March, I stepped off a chartered plane onto the sweltering tarmac in Port-au-Prince to volunteer at the University of Miami Hospital in Haiti. The field hospital was created by Project Medishare and the University of Miami Miller School of Medicine's Global Institute on January 21, 2010, just 11 days after the devastating earthquake destroyed much of the country's infrastructure and injured and killed hundreds of thousands of Haitians (1). The hospital was a four tent facility with 240 beds located at the Port-au-Prince airport. It was arguably the most comprehensive hospital in Haiti after the earthquake, with four operating rooms, medical, pediatric and neonatal intensive care units, a pediatric ward, a medical/surgical ward, an emergency room, triage, and wound care and orthopedic clinics for follow-up care. The field hospital moved to a permanent building at the Bernard Mevs Hospital in Port-au-Prince in June of 2010. It is run primarily by the University of Miami and other volunteers from around the United States who work tirelessly for 8-day stints.
Project Medishare, which was founded by Barth Green, M.D., Professor and Chairman of the Department of Neurosurgery, and Arthur Fournier, M.D., Professor of Family Medicine and Associate Dean for Community Health Affairs, at the University of Miami's Miller School of Medicine, has been working to provide sustainable health care in Haiti since 1994. As a medical student, I previously had the opportunity to volunteer in Haiti with Project Medishare on two separate occasions to provide primary care in rural villages. As a second postgraduate year (PGY-2) resident in the Department of Psychiatry and Behavioral Sciences at the University of Miami, I was eager to return to Haiti following the earthquake to provide care in any capacity needed.
My faculty mentors in psychiatry warned me to avoid pathologizing patients' normal responses to such extraordinary trauma. Haiti has suffered more than its share of disasters, but the January 12 earthquake was one of the worst natural disasters in history, with over 230,000 deaths and 1.3 million left homeless. Although I was there 8 weeks after the earthquake occurred, most Haitians affected by the catastrophe still did not have adequate access to food, water, health care, shelter, or security. Until these basic needs were met, mental health problems were, by necessity, considered secondary. I volunteered to work with the internal medicine team, partly because I had completed my intern year in internal medicine and felt comfortable ordering antibiotics and pain medications for postoperative patients. However, once my identity as a psychiatric resident was revealed, I provided much needed mental health care to Haitians as well as to some health care volunteers who were overwhelmed by the experience.
The resilience and pride of the Haitian people is deep-rooted. Haiti was the world's first independent black republic, the first independent state of Latin America, and the only nation to be formed from a successful slave rebellion. Prior to its independence in 1804, Haiti was the richest French colony in the New World. Haiti's economy was crippled when France required the small nation to pay a hefty indemnity in order to be recognized as an independent nation. Haiti has since been plagued with corrupt leadership, military uprisings, foreign occupation, and environmental devastation. Eighty percent of the population lives in poverty, half in extreme poverty. It is the least developed country in the Americas. According to the United Nation's Human Development Index, Haiti ranks 149 of 182 countries (2).
Haiti lacks a coordinated mental heath care system. There are two psychiatric hospitals in the country. Défilé de Beudet in Croix-des-Bouquets is the sole hospital for the chronically mentally ill. Mars and Kline Psychiatric Center in Port-Au-Prince is the only hospital for acute mental illness. It is a 52-year-old dilapidated facility, which is severely understaffed and under-resourced (3). Both hospitals were damaged in the earthquake but are still in use. Outpatient mental health services are also limited. There are only about 15 psychiatrists serving the country of nine million people (3). Many Haitians rely on spiritual and religious strength to deal with their mental health problems. However, this may not be enough support as the intense stressors of losing family members, homes, and employment continue to affect individuals and communities.
In Haiti, mental illness is heavily stigmatized. The Creole language lacks many of the Western psychological terms to explain symptoms (4). Depression is expressed in terms of headaches, back pain, fatigue, poor appetite, or feeling empty. It is thought by some to be due to a Vodou (also spelled Voodoo) curse or excessive worry. Depression is treated with family support, and it is rare for a patient to seek professional medical care. Psychotherapy may not be accepted because the treatment of personal problems is viewed as a family or religious matter. Moreover, the availability of evidence-based psychotherapy is severely limited. Sezisman is a culture-bound syndrome in Haiti, similar to ataque de nervios, which is well described in the psychiatric literature (5). Literally meaning "seized-up-ness," sezisman is a state of paralysis provoked by the shock of unexpected events. Symptoms can last hours to days and include confusion, weeping, and refusing to speak or eat. Like depression, the ailment is treated with family support and guidance from a spiritual healer.
Religion plays a crucial role in all spheres of Haitian life. Vodou, which is a combination of West African traditions and Catholicism, is practiced by the majority of Haitians. According to the World Health Organization, Vodou is not only a religion but also a health care system. Illness is interpreted in Vodou as a need to establish a harmonious relationship with the spirit world. Psychiatric problems are attributed to supernatural forces and thought to be due to a spell, hex, or curse. Haitians often first visit a Vodou priest or priestess for healing, but are not opposed to also seeking care from medical professionals, if available. It is often helpful to consult spiritual leaders when treating mental illness to encourage adherence (4).
For months after the earthquake, hundreds of patients presented to triage and emergency rooms daily with symptoms related to psychiatric disorders (3). These patients had physical complaints such as heart palpitations, sweats, headaches, and memory problems. The symptoms usually started after the disaster and were often due to anxiety, depression, posttraumatic stress disorder (PTSD), or other syndromal psychiatric disorders. I encountered several patients requiring psychiatric care during my 8 days in Haiti. Table 1 lists four of those patients and the cultural context of their mental illnesses. The information was obtained in some instances via a Creole-speaking translator. Cases one and two describe patients who developed psychiatric illnesses due to the earthquake. The third case presents a woman whose chronic psychosis was likely exacerbated by the disaster. As demonstrated by the fourth case, the enormous stress of the disaster and its aftermath impacted not only Haitians but also relief workers.
I encountered multiple cultural barriers that proved challenging when assessing a psychiatric patient. One barrier was my inability to speak Creole. Since the interpreters were educated Haitians, they were often viewed by patients to be from a higher socioeconomic class, creating an uneven power dynamic. The majority of the translators were young men, making interviews with women and girls difficult at times. Many Haitians were reluctant to divulge their symptoms to a foreign doctor since mental illness is often viewed as a family matter.
Understanding the religious and cultural context of mental health aided in my ability to properly interpret symptoms and provide appropriate treatment. I cared for a young woman who appeared anxious and paranoid. She initially went to a hospital in the Dominican Republic for internal fixation of a fracture, but her leg became infected, requiring an emergent amputation at the University of Miami field hospital. She suffered from phantom limb pain and panic attacks. The patient divulged to a volunteer Haitian-American nurse that she believed the American doctors "took" her leg unnecessarily, and she was suspicious of their motives. The patient's distrust of foreign aid workers is not uncommon and is based on the tumultuous history of foreign occupation in Haiti. This case demonstrates how understanding a patient's cultural background aids in interpreting symptoms.
My experience highlights the benefits of training psychiatric residents in cultural competence. Residents must learn to identify their own cultural biases, appreciate differences, and interpret nuances in meaning. In 2008, Academic Psychiatry dedicated a special issue to culture and psychiatric education. The issue presented many innovative ways to incorporate cultural competency in residency training. Practicing transcultural psychiatry on an ongoing basis prepares residents to appropriately care for the increasingly diverse patient population (6). An international experience provides immeasurable value to psychiatric training. Immersion in a culture has a much greater impact than reading or hearing about how to approach a patient in a culturally competent manner. In addition, practicing in a resource-poor setting provides unique challenges and reveals the economic and ethical dilemmas of establishing adequate individual care along with sustainable population-based infrastructure. My work in Haiti has motivated me to further study the cultural influences on mental health and has shaped my interest in becoming an academic psychiatrist.
At the time of submission, Dr. McShane reported no competing interests.
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