Innovation: Marking 10 Years of Mental Health Care in Haiti

Content advisory: This article talks about sensitive issues including suicide and mental illness.

Tatiana Therosme gathered herself for a moment before talking about a young woman, born with HIV, who battled severe depression for years because of stigmatization and mistreatment resulting from people’s perceptions of her diagnosis.

Therosme first learned of the woman, Fabiola Noel, through a fellow staff member for Zanmi Lasante, as Partners In Health is known in Haiti.

“I was the primary clinician provider, and the nurse called me because she had tried to kill herself,” said Therosme, community health worker supervisor for Zanmi Lasante.

What followed was a relationship of support and clinical care that has stretched over years, ever since that phone call.

Therosme and other members of Zanmi Lasante’s mental health team quickly began seeing Noel regularly. Therosme learned that Noel’s peers had repeatedly treated her badly, as had a teacher at school.

“Because of the context of her HIV, because of the context of stigmatization…she really faced many, many difficulties,” Therosme said.

Zanmi Lasante’s ability to support Noel and treat her clinically for anxiety and severe depression—caring for her mental health, as well as physical—is a testament to a mental health system that arose after Haiti’s devastating 2010 earthquake, through a partnership with Haiti’s national government.

Over the past decade, that system has grown to serve a population of more than 1.3 million across Haiti’s Central Plateau and lower Artibonite regions, providing care for depression, psychosis, epilepsy, and many other mental health conditions and neurologic disorders.

Between January 2016 and September 2019, for example, Zanmi Lasante’s mental health system delivered more than 28,000 patient visits, and served more than 6,300 patients at supported health facilities.  

A recently published article details those 10 years of growth, and describes the development of a comprehensive, community-based mental health system in the Caribbean nation, where public mental health services previously were not able to match what was needed. Additionally, the article describes challenges to care stemming from Haiti’s ongoing political and social instability, and finds that despite those challenges, high-quality mental health care can be delivered not only in Haiti, but also in other low-resource settings around the world.

The article, “Development of a comprehensive, sustained community mental health system in post-earthquake Haiti, 2010–2019,” was published in February by Cambridge University Press in the journal Global Mental Health. Co-authors include Pere Eddy Eustache, director of mental health and psychosocial services for Zanmi Lasante; Dr. Giuseppe “Bepi” Raviola, PIH’s director of mental health; Therosme; and several others.

“The dedication of various staff across Zanmi Lasante and PIH to maintaining the system and improving the model has led to ongoing program growth and longer-term commitment to build a better system, (offering) hope that anyone in Haiti living with a mental disorder can have access to free, quality mental health care,” the study states. “We can expect that the perception of the Zanmi Lasante program’s relevance as an antidote to despair from mental suffering, both in communities and in the health system, will only increase the demand for services with time.”

Noel, whose name has been changed to prevent further abuse, is an example of how much people can achieve when the crushing burdens of mental disorders are lifted.

Therosme recalled that Noel assumed she would die young because of her HIV, so she never believed she could become a nurse or clinician.

“I remember working together to see what her next plan could be,” Therosme said. “She didn’t think she could make it, but she worked and completed her studies.”

Support, not stigma

Eustache said much of delivering mental health care in Haiti is about helping people understand that the trauma they are living with can be alleviated, and that receiving clinical care and local support are positive steps that should be shared, not stigmatized.

“The history of Haiti has been a history of violence. Structural violence, political violence, everything. People are exposed to poverty, and what I call social violence. And the new aspect of violence is what I call environmental, ecological violence,” Eustache said. “Sometimes people are living with trauma, and they are unaware of that.”

Eustache said ecological trauma from many sources can affect Haitians. “For example, every time there is a heavy rain, in the slums, walls collapse, followed by casualties,” he said. “Deforestation is strongly active in the destruction of the environment. This is what I call ecological violence.

“Drought caused by deforestation creates a cycle of hunger, pushing people to cut trees and make charcoal, destroying the environment, which becomes more and more threatening for people who are more and more vulnerable to trauma,” he continued.

Eustache said many of the people who receive mental health care from Zanmi Lasante show behaviors that are related to trauma they experienced in the past, and now appears in other forms.

“This is something we live on a daily basis,” he said.

“People don’t know how to phrase it, how to verbalize it,” Eustache added. “But we need to remain aware that Haiti is a country that has been prone to trauma.”

The earthquake on Jan. 12, 2010, struck about 15 miles southwest of Port-au-Prince, Haiti’s capital. The disaster killed nearly 300,000 people, injured hundreds of thousands more, and devastated social services and health care infrastructure.

In the weeks that followed, Haiti’s Minister of Health contacted Zanmi Lasante to request support in developing a national mental health system.

Service, not scarcity

The ministry’s request, initially made in February of 2010, was based on Zanmi Lasante’s previous success in addressing HIV and TB from a community-based model of care. That model included mental health services, with community health workers playing a key role in providing access and support.  Government and health leaders in Haiti believed the model also could be effective for addressing the growing burden of mental illness, itself, as an independent issue outside the framework of any other disease.

“After the earthquake we were aware that the need for mental health would be huge, and we needed to understand those expectations,” Eustache said. “So, we started thinking about a mental health program.”

Eustache and Raviola worked closely together, starting the week of the earthquake, to bring to reality a model for a community-based program that could be tried and tested in the regions where Zanmi Lasante works.

Therosme took Eustache’s comment a step further, saying that Zanmi Lasante jumped on the opportunity to build a structured mental health program that could fill gaps in staff recruitment, training, development of mental health specialists, and more. 

Those gaps had long been significant in Haiti, where the majority of people addressed mental health care through traditional treatment channels, such as religious leaders and local healers. Language barriers and local customs often enabled religious and community leaders to build trusting relationships with patients, as opposed to doctors in Port-au-Prince or other urban areas, often far from people’s homes. Financial barriers also played a role.

Eustache said that at Haiti’s two psychiatric hospitals, Beudet Hospital and the Mars and Kline Psychiatric Center, both in Port-au-Prince, the government pays clinicians’ salaries, but remaining costs are laid on patients and their families.

That means people from rural areas often cannot afford to not only travel to the capital, but also support a hospitalized family member during extended care. As a result, many people would avoid traveling to Port-au-Prince and instead seek local care from traditional healers.

These were just some of the factors forming the backdrop as an initial assessment, begun in March 2011, examined the setting for mental health programs in Haiti.

Building a system

The project began with an initial assessment of the local context—beliefs, attitudes and perspectives related to mental health care practice, and priorities. It engaged 15 focus groups and included 11 individual interviews with community members, community health workers, facility-based health workers, people living with mental illness and their families, and religious leaders, including houngan or voudou priests, manbo or voudou priestesses, and Catholic and Protestant priests.

The assessment found that, for respondents, the stressful conditions related to poverty experienced in many parts of the country, exacerbated by the earthquake, left everyone vulnerable to all manifestations of sadness and dysthymia, depression, suicide and psychosis.

It also found that traditional healers desired a formal mental health system, including psychological treatments, with which to collaborate.

This informed Zanmi Lasante’s commitment to build a formal mental health system, in large part, as a response to the devastating disaster. The growing team began by developing care pathways and protocols for depression, psychotic disorders and epilepsy, with the support of Grand Challenges Canada. 

“We consider that the earthquake has been an opportunity to raise awareness, and raise funding, to help us maintain the program and make sure that more and more people can get access to care that we are providing,” Eustache said. “We lost 300,000 people—that’s huge for a small country like Haiti. We say that these people shouldn’t have died for nothing.”

Zanmi Lasante’s immediate mental health response after the earthquake was providing care for people who had been displaced and were staying in temporary camps. That work evolved into community-based care, built on the foundation of community health workers and referrals to clinics or hospitals, where clinicians could assess patients and develop long-term care plans.

“What was accomplished by Zanmi Lasante in developing this system has been truly remarkable,” Raviola said. “Clinicians worked under the most challenging circumstances to support people living with unaddressed mental disorders that pre-existed the earthquake, trauma from the earthquake, the effects of additional disasters including the cholera crisis and multiple hurricanes, as well as political violence. The Haiti work also laid the groundwork for PIH’s cross-site learning collaborative in mental health care delivery, which to us represents a model of trans-national dialogue and sharing of experiences and lessons.”

Between 2010 and 2015, the Zanmi Lasante and PIH cross-site teams developed a system based on five key skill sets for delivering mental health care in low-resource settings, and five key implementation rules.  These include:

Skill sets:  

• case-finding, engagement, follow-up, and psychoeducation;
• targeted psychological interventions;
• medication management;
• supervision and consultation; and
• quality oversight

Implementation rules:

• assess context;
• identify and map priority care pathways;
• specify decision support tools;
• use QI practices; and
• address sustainability, management, and capacity-building

This process of describing the essential, effective elements of a basic system of care informed learning processes at other PIH sites in important ways, as the PIH cross-site team developed dialogue across all of the sites to build similar, and different, models of care based on local priorities. The Haiti case, for example, is now a key teaching tool for a course at Harvard School of Public Health called “Case Studies in Global Mental Health Delivery.”

Stability, amid instability

All of the skill sets and implementation rules tested in Haiti are delivered in a social and economic setting that has been turbulent, not just in the earthquake’s aftermath, but also in very recent years and to the present.

Three different presidents have served Haiti since 2015, amid constitutional crises and frequent civil protests, fueled by allegations of electoral fraud and government misuse of billions of dollars.

In 2016, Hurricane Matthew ravaged southern Haiti and displaced 175,000 people, many of whom faced a cholera epidemic, and food shortages brought by widespread damage to crops and livestock.

By 2017, 38,000 people were still living in displacement camps built after the 2010 earthquake. The following year brought more waves of street protests, both peaceful and violent, during a new period of national lockdown, known as peyi lòk. Schools closed, roads were blocked, and the country was brought to a standstill, slowing the economy and worsening poverty.

All of these crises have had significant effects on the well-being of clinical staff and caregivers themselves.

“At a human level, significant challenges currently make service delivery extremely difficult due to the contingencies of the daily reality that providers, coordinators, and managers have been facing over the past decade, a situation that has worsened since 2017,” the 10-year paper notes.

‘We still need to fight’

Despite all of those challenges, Zanmi Lasante’s mental health team has continued to show up, every day, to provide vital care and support—to people including the young woman with HIV.

Therosme said that woman now is a nurse administrator and social worker in a Zanmi Lasante hospital, accompanying people with HIV and tuberculosis, supporting their care and social assistance.

“She’s come far—she never imagined a day when she would be where she is now,” Therosme said. “Now she is talking about having a child.”

Eustache was sitting next to Therosme as she spoke, and noted her emotion.

“Tatiana is moved to tears telling this story,” he said.

Eustache said that Zanmi Lasante’s mental health mission is at its core about connection, in a country that remains essentially divided into rural and urban societies. Rural Haiti, he said, “has been totally excluded in terms of services and access to care,” along with education, public services, and more.

“Historically, Haiti has been going as a nation with two different societies—like two trains going in the same direction that cannot meet together,” Eustache said. “In our work as Zanmi Lasante, we say that our main goal is to make these people part of the whole society, with access to care that has been denied to them.”

Joining those train tracks will require continued collaboration between Zanmi Lasante, PIH mental health programs around the world, and other partners across Haiti.

“All we have accomplished as milestones is a joint effort from the Zanmi Lasante mental health program and the PIH cross-site mental health program,” Eustache said. “This is a joint effort, with a team spirit.

“(And) we have not done enough,” he added. “We still need to fight, to work.”