In the acute phase of the earthquake response—in addition to covering the medical needs of 1.2 million people living in the original ZL catchment area in central Haiti—PIH/ZL took on the provision of medical care to internally displaced persons (IDPs) in four camps in Port-au-Prince with a total population of approximately 100,000 (see ). A small group within PIH/ZL, drawn from a range of disciplines and referred to below as the Team, took upon itself the responsibility of advocating for a sustained mental health service response.
Partners in Health/Zanmi Lasante activity in post-earthquake Haiti, 2010. CHW, community health worker; IDP, internally displaced person; ZL, Zanmi Lasante.
Initial actions included assessments of existing services within and outside of the ZL catchment area, as well as meetings with Haitian mental health service leaders in Port-au-Prince, where the earthquake had caused many fatalities and the most severe physical damage. The Team worked with representatives from other organizations in the United Nations Cluster group process, meeting on a biweekly basis to discuss coordinated service strategies. Representatives of the Team met with Haiti's minister of health, facilitated by PIH's medical director. The minister acknowledged that the mental health needs of the population had been neglected prior to the earthquake and that the disaster had exposed a public sector mental health system in disrepair. People with severe mental and developmental disorders were languishing in neglected, locked inpatient wards or wandering in the streets, and few psychiatrists were working in Haiti.23–25
The minister requested PIH/ZL's support in developing a national mental health response to the disaster. The Team proposed to the Ministry of Health an initiative by which PIH/ZL would use its initial response as a foundation for a sustained, longer-term organizational commitment to developing decentralized mental health services within the ZL health care system. This initiative would serve as a model for developing a community-based mental health service structure that would be shared with the government as part of a broader planning effort organized under the leadership of the ministry.
The Team understood that building a system for mental health care in this context would require a systematic, integrated, evidence-based, multisectoral approach that prioritized local knowledge, as well as a range of cooperation and expertise larger than any single organization or institution, or the government, could provide. In the years prior to the earthquake, the ZL psychosocial program had focused primarily on the socioeconomic, educational, and psychological needs of children and families affected by HIV/AIDS or TB.26
Importantly, these services were buttressed by the Program on Social and Economic Rights, a system of social and economic support created by PIH/ZL to address core determinants of poor health such as lack of food, housing, or water. This preexisting medical and psychosocial platform for basic service delivery operates on the assumption that emotional distress in the context of poverty requires social and political action, as well as clinical intervention, to address preventable root causes. This platform, along with its approach, would provide a helpful launching point for the PIH/ZL post-earthquake mental health response.
In February 2010, the newly integrated PIH/ZL mental health and psychosocial Team led a series of memorial services at ZL hospital sites to commemorate both loss and survival, and to provide comfort, solace, and emotional healing to staff at ZL hospitals. The ZL psychosocial and mental health service director, a Haitian priest and psychologist, developed protocols for religious mourning services combining spiritual and psychological language. This template was adopted by the Haitian Ministry of Health and was used for national radio addresses emphasizing the importance of mourning and—explicitly—mental health. Community health workers living and working in the Port-au-Prince IDP settlements were taught to deliver these ceremonies to the population in an organized way, integrating music and communal activities, and facilitating collective grieving.
Groups identified as being especially vulnerable to mental health problems included people who sustained physical injuries and amputations, IDPs, individuals at risk of gender-based violence and children in need of protection.27–32
The earthquake's effects were also recognized to extend to people with preexisting mental disorders or significant prior histories of trauma and loss, Haitians living abroad and in the Diaspora, and health care providers and others responding to the earthquake relief effort or providing ongoing services.33–38
The Team became engaged in three primary activities: (1) finding, supporting, and treating both basic psychosocial and acute mental health needs of IDPs, (2) building capacity for overall psychosocial and mental health services, both preventive and clinical, at ZL sites, and (3) supporting the Haitian Ministry of Health in developing a national mental health plan. The Team drew from current evidence and best-practice recommendations to provide an initial mental health and psychosocial response to the emergency, consisting of (1) support to staff members. (2) launching of child- and family-specific social activities, (3) development of community programs, (4) training in psychological first aid, adapted to the Haitian context for use by Haitian psychologists and social workers, and (5) implementation of enhanced mental health services at all ZL sites, including training of primary care physicians in managing acute distress states and in using psychopharmacology. The psychopharmacologic formulary at ZL hospital sites was expanded to contain a range of options for managing acute distress states and more chronic mental illness. All of these interventions helped to stabilize individuals and communities during the early phases of the emergency.
The Team advocated internally for an increased commitment by PIH to mental health services. Within four months of the earthquake the Team obtained the resources to bring staffing numbers to 17 psychologists (up from 3) and 50 social workers and social work assistants (up from 20). These additional staff members were all Haitian nationals, and most had completed bachelor's-level training. Of the new ZL staff, 8 psychologists, 6 social workers, and 13 mental health–focused community health workers were deployed in the IDP settlements. These community health workers had themselves already been living in the IDP settlements and were selected by settlement citizen committees to help refer people suffering from acute distress responses to the clinicians working at the free-of-charge primary health clinics run by PIH/ZL. The primary care clinicians, psychologists, and pharmacists received training in psychopharmacology to prescribe medications, acting as an on-site multidisci-plinary team with the support of a Haitian psychiatrist. Initial training and supervision were provided by several visiting U.S. clinicians (psychiatrists and a psychologist), all with knowledge of the Haitian context and all drawing upon curricular materials (translated into both French and Creole) developed after the earthquake with attention to the expanded psychopharmacologic formulary at ZL. The ZL mental health clinicians also provided individual and group psychotherapy based on the training that they had received prior to the earthquake. PIH/ZL sought to replicate this basic collaborative care service model at all ZL hospital sites, adapted to the skill sets of those working in community health, primary care, and mental health consultation-liaison capacities, with one psychiatrist serving the entire system. Each ZL hospital site was assigned one psychologist, whose responsibilities were broadened to encompass both psychosocial services related to HIV/TB and management of clinically severe presentations, including trauma-related symptoms and chronic mental disorders. The psychologists were also charged with assembling multidisciplinary teams at each hospital site in the Central Plateau and Artibonite, with each team to include at least one physician for prescribing medications. At one-and-a-half years after the earthquake, ZL staff had documented 20,000 individual and group appointments for mental health and psychosocial needs in the IDP settlements and at ZL hospital sites.
In addition to their clinical work, the IDP settlement teams organized memorial services, games for children, community educational and psychosocial support activities, and psychoeducational meetings. Aware that more than a quarter of the population living in the IDP settlements were children under five years of age, PIH/ZL expanded child protection efforts by creating safe spaces for children and actively reporting unaccompanied children to a national referral center run by UNICEF. Within the ZL catchment area, special efforts were also made to embed psychological support within a new rehabilitation program for amputees. As rehabilitation teams followed patients into the community upon hospital discharge, they increasingly came into contact with people with preexisting mental disorders and disabilities requiring intervention.
Ten months after the earthquake, a cholera outbreak hit an already devastated Haiti, causing widespread suffering, death, and fear. Those contracting the illness were stigmatized, as the illness's precipitously rapid lethality was compounded by a shortage of access to health services, inadequate water supply, and lack of sanitation, particularly in rural areas. The Team was once again mobilized to provide memorial services—and, as had occurred after the earthquake, on short notice because of the need for immediate burial. These ceremonies, adapted for the families of patients who died unexpectedly, were designed to help them express their grief in an environment ripe with fear of a disease that had been absent from the Haitian context for more than a century. The Team also developed a support group curriculum for cholera survivors to assist them in reintegrating into their families and regaining self-confidence and a positive body image. These groups were adapted from a family-focused, psychosocial group intervention for children with HIV and their caregivers that ZL had been utilizing at hospital and clinic sites prior to the earthquake. Unexpectedly, the need for these groups became increasingly urgent as patients were being abandoned at treatment centers or refused entry to their homes due to fear that they would spread the disease.