By Jennifer Browning
Students from Emory University have been working with Project Medishare staff in Haiti’s Central Plateau this summer trying to understand how mental health is understood in rural Haiti. The students hope that this is the first of many trips to work toward improving psychosocial services in the Central Plateau.
“This summer is the first of hopefully many steps,” Bonnie Fullard said. “Right now we are trying to lay the groundwork for some type of psychosocial support through Project Medishare. We are trying to understand the needs the way mental health is understood and discussed in rural Haiti and the resources that are already in place.”
Fullard who is a second year Masters in Public Health (MPH) student also working toward her doctorate in anthropology is spearheading the focus group discussions on the project while working training the research assistants.
“We are working at mapping these current local resources available, but at the same time we are using resources used in the U.S. and sort of adapting them here,” Fullard said.
Hunter Keys, a first year nursing student at Emory, said one of the major challenges the research group faces is the language. While the group has been taking Creole lessons at the university to prepare them for this project, there is still an issue about how the language translates in regards to mental health.
“I think one of the challenges is getting a sense of the language and an understanding of the language barriers,” Keys said. “We are really trying to get an understanding of the local language and how mental health is expressed here.”
To assist them with this, the research group found four English/French translators who also are serving as research assistants to help them understand the true understanding of mental health in the rural area.
“One of the examples is the concept of emotions, for instance, a word that we use to describe as emotions for example is the French word, sentiment, is feelings,” Keys said, “but we have been told that in Creole sentiment is reserved for amorous relationships, so sitting around in a group talking about sentiment might conjure up the wrong images. “
Keys said that even the Creole word for mental health doesn’t necessarily translate.
“Even the translation for mental health in Creole, santé mentale doesn’t necessarily translate among rural Haitians. Maladie mentale –a mental illness is immediately thought of as being on the extreme end of mental illness and we are trying to take a more global approach to a more encompassing view of mental illness.”
Fullard agreed with Hunter in that in rural Haiti there is not an actual term for mental health.
“In that sense it is something that is not really talked about,” Fullard said. “When it is talked about it is a really stigmatized topic where people here immediately describe it as “fou” or “crazy” so that it is hard to talk about the things we want to get to, which are the more mild to moderate disorders such as depression, anxiety, and post-traumatic stress disorder(PTSD).”
Aimée Brewster who is a first-year MPH student said that locally, the research team has found a connection between mental illness and local folklore or voodoo. As part of their study to better understand this, the group has interviewed voodoo as well as Catholic priests in the area.
“We have seen a strong association between what is perceived as mental illness and voodoo, so that has been interesting in learning how people view mental illness or the cause of mental illness,” Brewster said. “Even in understanding their views of the extreme sense of ‘fou’ —that being a curse or a spell cast on someone out of jealousy. So that has been interesting to learn how voodoo is correlated with how people are suffering from mental illness.”
Third-year medical student Nayla Khoury said that even poverty plays into the reasons that people suspect why someone is suffering from an extreme mental illness.
“We got a chance to talk to a priest who had a really interesting social justice perspective on why people go crazy,” Khoury said. “One was voodoo jealousy curses and another reason was that there is no justice system here, so when people see the haves and have-nots, in his point of view, other people go “crazy” when they have no other way to get over their poverty.”
The research group is also working to build relationships with people in Haiti who are already providing psychosocial services.
“We have connected with a few people, specifically Zanmi Lasante, who has a division of psychosocial services and they have around 17 psychologists now working in Haiti, one being at the hospital in Thomonde,” Khoury said. “So there is a presence, but we haven’t formally sat down with anyone yet to discuss what exactly is being done, what their system is for diagnosis, screening and treating people with mental illness.”
A requirement for the group is for them to work on documenting the sparse availability of mental health services in the rural areas and report it to the Haitian Ministry of Health in order to show what is really needed.
The group also hopes to culturally validate a screener typically used in the United States. A screener is a set of questions that could be asked in a clinical setting by a non-professional mental health person in order to determine whether a person should be referred to a specialist.
Khoury said that many mental health teams have come to Haiti post-earthquake and are more than likely using these various screeners primarily in Port-au-Prince to help determine specifically PTSD.
“There are lots of mental health teams that have come post-earthquake that are mostly focused in Port-au-Prince and that are focusing on post-traumatic stress,” she said, “but the question is, who knows how many will of those teams will stay and who knows what they are using to try and screen and treat people.”
The group agrees that language becomes a major challenge also in trying to figure out if these screeners make sense once they are translated.
“One of our goals is to culturally validate a screener not only by translating it into Creole,” Khoury said, “but to also have focus groups and speak with people to see does the screener even make sense to use with the people here.”
Khoury said that as a medical student, one of the challenges of the project is to get an “ethno-perspective” of what mental health is in rural Haiti.
“What I bring in terms of my own biases of what mental health is in the U.S. may or may not exist here,” she said. “Some describe people that may have psychosis or any number of problems, but they are really the people we would see on the street in tattered clothing and that is a huge stigma in itself in terms of the way people speak of these types of people.”
Khoury said that it is appearing that resources for people with such severe mental health issues may be few to none.
“It seems here that there are no resources for them,” she said. “We have been told that people who are called ‘fou’ might go up to the church to pray or go to one of the possibly three psychiatric institutions that everyone describes as prisons. Such institutions are not somewhere people would actually want to refer someone who is actually suffering from an extreme mental disorder. So there isn’t really a place for those extreme cases of ‘fou,’ and there is nowhere to send anyone who may have mild to moderate disorders. So one of the challenges in the clinic is they don’t ask about [mental health issue] and they don’t look for it possibly because they wouldn’t have anyway to deal with it if someone where to come in with depression.”
While the group plans this to be an ongoing project, one of the group’s main outcome is to try to provide some training manuals and screeners for Project Medishare’s local staff.
“This will provide the medical staff a sort of an explanation as the best way to approach mental health as far as we can tell so far,” Fullard said. “So in the future we are trying to build on that foundation and figure out how Medishare can try to incorporate these into the clinics and mobile clinics.”
Khoury said this part of the study is really about laying the groundwork for understanding mental health in rural Haiti.
“It makes it more of a less tangible project at this point,” she said. “We are trying to see what is here now, what is being done, and what are people are interested in.”
Khoury said that in order for their study to progress it really comes back to understanding the local language as it relates to mental health.
“People ask, and at times, we ask ourselves too, should we be doing a more quantitative study to find out how many people are here suffering from mental illness,” Khoury said, “but we realize that before we can do that until we have the language down so we can talk about it.”
Aside from the language challenges, the group is working in Haiti during the rainy season, which has cut interviews and even workdays short because the roads are unreliable when they become saturated with mud. They all agreed that this can be frustrating when focusing on finishing the task at hand, however they welcome the challenges they face each day.
“The rain season is interesting here,” Khoury said. “Everything closes right before it rains. Days are cut short when storm clouds appear for fear of being stuck out on the dirt road. But it really is a wonderful place. It is challenging and inspiring.”