Annalee Giesbrecht is the MCC Haiti Advocacy and Communications Co-ordinator. Read more about MCC’s work in Haiti at haitimcc.org.
At 3 p.m., after a full day in the waiting room of Haiti’s central tax office, Joseph Saingelus accepted he wasn’t going to get the documents he needed before the office closed at 4 p.m. He decided to leave—his accounting class started at 4 p.m., and Saingelus is never late. He could try again the next day.
But the next day, the tax office was gone. An hour into Saingelus’s accounting class, on Jan. 12, 2010, a magnitude 7.1 earthquake struck Haiti’s impoverished, densely populated capital. Unable to get down from the top floor of the school, Saingelus remained where he was as the school shifted, cracked, but remained standing.
After the shaking stopped, Saingelus saw destruction all around him. He didn’t know it then, but hundreds of thousands of people had died or would die in the coming hours and days; 2 million people were now homeless. The tax building, where Saingelus had been waiting all day, was completely destroyed, killing the director and other people still inside at the time of the earthquake.
Throughout the night and for several days after, aftershocks rocked the city; Saingelus and other survivors slept outside, in their yards or public spaces, too terrified to venture inside the buildings left standing. It’s estimated that as many as 91 percent of those who survived the earthquake had a close friend or family member killed or severely injured.
On Oct. 6, 2018, the first significant earthquake since 2010 struck near Port-de-Paix, on Haiti’s northern coast. The tremors from the magnitude 5.9 quake reached as far as Haiti’s capital, over 124 miles (200 kilometers) to the south.
“I was very anxious, I ran outside right away,” said Saingelus, who had been in his home in Port-au-Prince this time. He’s never forgotten the 2010 earthquake, known simply as “12 January” throughout Haiti.
“If a big truck goes by and I feel the earth shaking, my heart starts pounding. I know it (an earthquake) could happen again at any moment.”
No damage or injuries were registered in the capital as a result of the Oct. 6 earthquake but for survivors of the 2010 earthquake, it was a visceral reminder of the trauma they suffered eight years ago. These reminders are difficult even for those like Saingelus, whose anxiety has diminished over time, even if it has not disappeared completely. But for those living with an acute mental health condition called Post-Traumatic Stress Disorder (PTSD), reliving that experience is devastating.
Joseph Saingelus. MCC Photo/Ted Oswald
A nation vulnerable to trauma
Before 2010, decades of political violence, internal displacement and poverty had already taken a psychological toll on Haiti’s citizens. The island of Hispaniola is located in the Atlantic hurricane belt and balanced between not one but two fault lines, one running along Haiti’s southern peninsula and past Port-au-Prince, the other skirting its northern coast, near Port-de-Paix. But it’s not only Haiti’s history and location that make the country vulnerable to traumatic events.
“People in Haiti would only be exposed to a fraction of the traumatic incidents they are, if Haiti was a wealthier country, with better infrastructure, a high-quality health and emergency response system, stable government, and strong rule of law,” says MCC’s health coordinator, Paul Shetler Fast, based in Port-au-Prince. According to the 2017 World Risk Report, Haiti is ranked the world’s fourth most vulnerable country to natural disasters, with the fourth-lowest coping capacity.
Post-traumatic stress
It should come as no surprise, then, that rates of PTSD in Port-au-Prince are high—between 25 and 37 percent, according to studies conducted in 2013 and 2014, roughly comparable to the rates found in combat veterans and five times the rate in the general population in the United States.
The National Institute of Mental Health describes PTSD as a “changed or damaged version” of the body’s natural fight-flight-or-freeze response to danger. It can manifest itself in a variety of ways, including upsetting memories, nightmares, feeling on edge, and/or severe anxiety. These symptoms are common after a traumatic event and generally diminish over time; however, for individuals with PTSD, they continue for prolonged periods and take a serious toll on all aspects of their life. Without treatment, PTSD can result in high rates of depression, anxiety, substance use, suicide, homelessness, unemployment, risky sexual behaviors, and domestic violence, as well as complicating new or pre-existing conditions like HIV, tuberculosis, diabetes, or heart disease.
Medical care in Haiti is expensive and difficult to access, and mental health care is even more so. As a result, conditions that can develop from exposure to trauma, like depression and anxiety, often go untreated. There is currently no treatment available for PTSD in Haiti. According to Dr. Giuseppe Raviola, mental health director for Partners in Health and director of the Program in Global Mental Health and Social Change at Harvard University the gap between the number of people who have a mental disorder and the number of people who receive treatment for it is as high as 90 percent in the world’s least-resourced countries—like Haiti.
A class takes place at the public school in Bingo despite serious structural damage caused by the October 6th, 2018, earthquake. After the earthquake, many parents that their children are afraid to enter buildings for fear they’ll collapse, and some are afraid to go to school. MCC photo/Annalee Giesbrecht
A significant public health problem
“When historical trauma and poverty are overlaid with acute stressors such as exposure to natural disaster, war or political violence, the direct threats to mental health become all the more menacing,” says Raviola.
“We call this ‘acute-on-chronic’ stress, and it has significant impacts on the ability of people to realize their own potential, cope with the normal stresses of life, work productively and fruitfully, and be able to make a contribution to her or his community–the definition of mental health.”
When untreated, PTSD takes a significant toll on an individual’s physical and mental health; however, because it affects families, communities, and society at large, it’s also a public health problem. Parents with PTSD often struggle to hold down jobs and fulfill their roles as providers and care-takers. In Haiti, this means that children of parents with PTSD are less likely to go to school and receive an education. Rates of mental and physical health issues in children of parents with PTSD are high.
“In addition, it’s important to remember that PTSD only develops after exposure to trauma, which is in and of itself a socially mediated dynamic,” says Paul Shetler Fast. “Addressing PTSD as a public health problem means taking seriously all the downstream consequences of untreated clinical PTSD as well as all the contextual factors that contribute to its development.”
An MCC relief distribution in the community of Bingo, near the city of Jean Rabel, which was hit hard by the October 6th, 2018, earthquake. MCC photo/Annalee Giesbrecht
Integrating mental health care into public health, peacebuilding, and development
This is why MCC is working to support effective, evidence-based treatments for people in Haiti who experience trauma, including PTSD.
Rebecca Shetler Fast is a licensed clinical social worker with a specialty in trauma who now lives and works in Port-au-Prince as MCC’s representative for Haiti.
“There is already a huge need for basic mental health services, and an absolute absence of effective care for people with PTSD, people for whom each day is a living hell as they relieve their most traumatic memories. Everyone deserves relief from this terrible suffering.”
MCC works with Zanmi Lasante, Partners in Health’s sister organization in Haiti, as one of several funders supporting a team of 14 psychologists and 31 community health workers who provide mental health care to people who would not otherwise have access or resources to access mental health treatment. In addition, MCC is working with Zanmi Lasante’s mental health team as they develop the first evidence-based clinical PTSD intervention in Haiti. This treatment is an adapted form of cognitive processing therapy (CPT), a mental health treatment modality that addresses the underlying causes of PTSD by helping patients shift their beliefs about the cause of the trauma from unhelpful self-blame to more constructive, nuanced perspectives.
Recovery is possible
As Haitians are once again exposed to trauma as the result of natural disaster, we are reminded of the pressing need for effective, accessible mental health care in Haiti and around the world. PTSD is a serious public health issue, but it is treatable. With the appropriate funding and support, evidence-based treatment like that being developed by Zanmi Lasante can be an effective intervention.
“Prior to this project, people with PTSD in Haiti had very little chance of recovering,” says Rebecca Shetler Fast. “Now there will be more opportunity for people in Haiti to experience relief and even recover from the long-term effects of acute trauma.”
The long term effects of the earthquake that destroyed much of Port-au-Prince in 2010 are evident not just in architectural damage and remaining makeshift shelters, like this one in a public square in the neighborhood of Ti Plas Kazo, but also in the significant physical and mental health problems faced by the many survivors living with PTSD. MCC photo/Annalee Giesbrecht.