Integrating mental health intoprimary health care settings afteran emergency: lessons from Haiti
Nick Rose, Peter Hughes, Sherese Ali & LynneJones
Following the 2010 Haiti earthquake, there was a
need for specialist services for severely mentally ill
people whowere presenting to the emergency medical
clinics set up for displaced people. That need was
unmet. Using guidelines drawn up by the Inter-
Agency Standing Committee (IASC), and piloting
theHealth Information System(HIS) ofdiagnostic
categories in mental health, weekly mental health
clinics were begun in eight mobile clinics. A psy-
chiatric liaison service was also started in the main
casualty hospital. Haitian general practitioners
and psychosocial workers, who received on-the-job
training and supervision from the authors, ran these
services. This integrated mental health/primary
health care modelwas successful in engagingseverely
mentally ill patients in treatment; however, the
scale of the disaster meant that only a relatively
small proportion of the displaced population could
access help. This limitation raised a number of
questions about the practicality and sustainability
of the IASC model in resource poor countries, with
poorly developed community services, hit by large
scale emergencies, which the authors address.
Keywords: earthquake, Haiti, large scaleemergencies, mental health services,resource poor countries
The Haitian Government reported thatan estimated 220,000 people were killedand 1.5 million displaced in the 2010Haitian earthquake (United Nations HighCommissioner for Refugees (UNHCR),2010), although a more recent draft report
commissioned by the United States Agencyfor International Development (USAID)has recently claimed that the mortality¢gures may have been overestimated at leastthreefold (BBC, 2011). Nevertheless, what-ever the ¢nal estimate, the scale of thedisaster was immense; occurring in acountry where four out of ¢ve people alreadylived below the poverty line, and where thehealth infrastructure was weak. Haitiranks last for health care spending in theWestern Hemisphere (World Bank, 2006)with health provision unregulated andpatchy. Only 30% of health facilities werepublic, mostly in urban areas, and 70% ofrural health services were provided bynongovernmental organisations (NGOs),with 40% of the rural population havingno access to primary health care (WorldBank, 2006; WHO, 2010a). Mental healthresources were highly centralised, and con-sisted of two psychiatric hospitals in Port-au-Prince, both of which were understa¡edand in apoor state of repair.Therewere only0.2 psychiatrists per 100,000 general popu-lation, as compared to 11 per 100,000 in theUnited Kingdom (WHO, 2005), most work-ing in the capital city. Outside of Port-au-Prince, therewas little access to psychosocialsupport or e¡ective social services. Therewas, however, a widespread network oftraditional religious healers. Vodou beliefsare common in Haiti, and these beliefs sup-port a religious health care system that
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incorporates healing practices (WHO,2010a).Vodou beliefs are also re£ected in thepresentation and causal explanation ofsevere mental illness. This fragile healthinfrastructure was overwhelmed followingthe destruction of at least eight hospitals, aswell as the deaths and injuries of essentialpersonnel during the earthquake. A massiveaid e¡ort was mobilised, which includedattempts to meet the needs of those withsevere mental illness. This paper describeshow one group of mental health pro-fessionals undertook this task.
Meeting mental health needsfollowing large scale disastersWHO guidelines, for providing mentalhealth assistance after disasters, have pre-viously suggested that there are three groupsof distressed people, each requiring a di¡er-ent response (WHO, 2007). Those withmild psychological distress that resolves ina few days or weeks, and needs no speci¢cintervention, estimated at 20^40% of thea¡ected population; Those with moderateor severe psychological distress, who wouldbene¢t from basic non specialist, psycho-social interventions, such as psychological¢rst aid and interventions that strengthencommunity and family, are estimated at30^50% of the a¡ected population. Finally,are those with a mental disorder, the inci-dence of which appears to temporarilydouble following a disaster. Within this lastgroup, the prevalence of mild to moderatedisorders, such as mild to moderate depres-sion or anxiety, would be expected toincrease from a baseline of 10% (WHO,2004) to 20%, while the prevalence of severedisorders could rise from 2^3% to 3^4%.As a result, how to undertake psychosocialand mental health work after disasters haslong been the subject of debate. For example,there has been no agreement on the public
health value of the posttraumatic stressdisorder (PTSD) concept and no agreementon the appropriateness of ‘vertical’ traumafocused services (van Ommeren et al.,2005). The needs of people with severemental disorders, in post disaster situations,have also been slow to get recognition. AfterHurricane Katrina in 2005, it was estimatedthat the prevalence of severemental disorderalmost doubled from 6.1 to 11.3% of thea¡ected population, yet psychosocialagencies tended to focus on the immediatetraumatic responses (Kessler et al., 2006).This lack of consensus to the approachmeant that mental health was only brie£ydiscussed in the ¢rst edition of the Sphereguidelines on humanitarian standards, pro-duced by a group of leading internationalaid organisations in 1998 (published asThe Human Charter and Minimum Standards in
Disaster Response, commonly referred to asthe Sphere Handbook, currently in its 2011edition). Controversy continued during theAsianTsunami, when psychosocial agencieswere widely criticised for lack of agreedstandards and varying approaches. Thisexperience led directly to the creation ofthe Inter-Agency Standing Committee(IASC) task force set up to agree guidelinesfor the practice of mental health andpsycho-socialwork in emergency settings. Represen-tatives from 27 international governmentaland nongovernmental organisations workedover two years, in consultation with expertsfrom more than 100 nongovernmentalorganisations, academic institutions, andprofessional organisations. The resultingIASC Guidelines on Mental Health and Psycho-
social Support in Emergency Settings representan international consensus on the type ofcare, and care system that is suitablefor emergency situations (Inter-AgencyStanding Committee, 2007; Wessells & vanOmmeren, 2008).
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Rose et al.
The hierarchy of responses recommendedby the IASC guidelines includes: advocacyfor equitable and digni¢ed access to basicnecessities and protection for the majority;social interventions that reconnect disruptedfamilies and communities, and help themrestart their lives; more focused individualpsychosocial support for those who su¡ermore severe non pathological reactions;and clinical interventions for the mostseverely a¡ected minority. Other authorshave emphasised the importance of acknow-ledging and building on the naturalresilience of individuals and communities.Resilience is seen as a process rather thanan end point, and is reinforced throughstrategies such as psychological ¢rst aid,and enabling displaced communities to beas self-reliant as possible (Raphael, 2008;Bonanno et al., 2010).In relation to care for people with severemental disorders, the IASC guidancerecommends integrating mental healthprovision with primary care clinics (Box 1),
Box 1: Minimum response actionssevere mental disorders in emergMental Health and Psychosocial Supp
1. Assess situation (including surviving he2. Ensure adequate supplies of essential p3. Enable at least one member of emergen
provide frontline mental health care4. Train and supervise available PHC sta¡
mental disorders5. Avoid overburdening PHC workers wit6. Establish mental health care at additio
emergency rooms)7. Try to avoid creating parallelmental he
or narrow groups8. Inform population about the availabili9. Work with local community structures
severe mental disorders10. Be involved in all inter-agency coordin
which is consistent with the WHOstrategy for mental health provision inpoor nations (WHO, 2008). This guidancealso recommends giving appropriate sup-port to local services and institutionscaring for people with severe mental dis-orders and other mental and neurologicaldisabilities.Saraceno et al. (2007) have identi¢eda number of barriers to integrating mentalhealth services into primary care. One isthe work overload su¡ered by most primaryhealth care workers, which means they seethemselves as having no time for mentallyill patients. The second is providing short,theoretical training courses without followup supervision. These constraints mayresult in a failure to distinguish distress fromdisorder, and consequent overmedicalisa-tion, and overprescribing of psychotropicdrugs, for minor complaints. A third barriercan be the lack of psychotropic drugs, sothat even trained workers lack the meansto treat severe mental disorders.
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to address needs of people withencies (from IASC Guidelines onort in Emergency Settings)
alth capacity)sychiatric drugscy primary health care (PHC) team to
in the frontline care of severe
h multiple di¡erent training sessionsnal logical points of access (including
alth services focused on speci¢c diagnoses,
ty of mental health careto discover, visit, and assist people with
ation on mental health
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Intervention 2011, Volume 9, Number 3, Page 211 - 224
The IASC Guidelines address each of thesebarriers, recommending that theoreticaltraining is always accompanied by super-vised on-the-job training, and that primaryhealth care (PHC) sta¡ are assisted andtrained in time management to allowdedicated time for mental health work. Theguidelines also recommend training insimple psychological interventions for nonpathological distress, and rational prescrib-ing. Also important is investment in systemsof care, rather than individual sta¡ mem-bers, and ensuring that treatment conformsto international standards of care (Cohen,2001).The IASC recommended model of inte-grating mental and physical healthcare inemergency and con£ict zone situationsis now well established practice (vanOmmeren et al., 2005; Budosan et al., 2007;Jones et al., 2009; Rose, 2011; Mueller et al.,2011). However, the scale of the disaster inHaiti and the complete absence of com-munity based mental health care prior tothe earthquake provided a challengingopportunity to test the Guidelines in anemergency, resource poor setting ofimmense proportions.
Our response to the HaitiemergencyA rapid assessment of need was done within12 days after the earthquake. This includedcoordination with other local and inter-national agencies planning to providemental health and psychosocial care. Littleinformation was available on Haiti’s pre-existing mental health needs, thereforethe assessment included visiting both of thenational psychiatric hospitals in Port-au-Prince, and talking with surviving sta¡.Emergency clinics for displaced people, setupbyanumber of medical aid organisations,were also visited aswas themain Emergency
Room for Port^au-Prince situated in thegrounds of the partly destroyed UniversityHospital, l’Hopital de l’Universite¤ d’Etatd’Haiti (HUEH).At this stage, the International MedicalCorps was responsible for providing15 com-munity clinics, as well as Emergency Roomservices at HUEH.The assessment revealedthat the majority of people attending theemergency services reported feeling shockedand afraid, with common complaints ofpalpitations and a persistent feeling thatthe ‘ground was moving’. People were alsobeing seen with severe mood disorder andpsychotic illness, clinical problems that themedical teams were poorly equipped tomanage.The majority of the a¡ected populationwere living in overcrowded makeshiftshelters and/or crowded camps for displacedpeople. They were frustrated and angry atthe di⁄culties of obtaining basic necessities,and at the lack of security. Therefore,advocacy to change these conditions was apsychosocial priority from the start. Mostpeople had su¡ered losses of some kind.Some individuals had been trapped underthe rubble for long periods. A child patientof one of the authors had been discoveredafter nine days for example. Because of therapid disposal of bodies in mass graves andthe persistent problem of uncleared rubble,many had been unable to ¢nd or identifythe remains of their loved ones, whichmade mourning di⁄cult. Added to this, fearand stress was generated by continuinggovernment warnings of the likelihood ofnew quakes. Given these conditions, theresilience of the population and the degreeto which they were helping themselveswas remarkable. Markets appeared in themakeshift camps in the ¢rst days after thedisaster, as did small enterprises such asphone charging, hair dressing and the
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Rose et al.
sale of prostheses, crutches and wheelchairs.Assessment of the two psychiatric institu-tions revealed a particularly disturbingsituation. In the acute psychiatric hospitalnear the city centre, 11 of the original 100inpatients lived in degraded and insanitaryconditions with no running water, nopower, ¢lthy accommodation, no bedding,and no clothes.Many of the sta¡ were understandablypreoccupied with their own a¡airs, becausethey were bereaved, or their homes weredestroyed, and did not return to work forweeks. Those who did come to work had tocare for at least 150 outpatients a day in atent surrounded by an encampment of 120displaced families that had taken refuge inthe hospital yard.In the long stay hospital on the outskirtsof Port-au-Prince, many patients had runaway when the wall collapsed and theremainder slept in the open-air as the roomswere considered unsafe.At least 90 international and localagencies were o¡ering psychosocial supportafter the earthquake. Coordination tookplace through the UN led mental healthand psychosocial support sub-cluster, whichmet twice a week. A representative fromthe Haitian Ministry of Health was jointchair of this meeting. Mapping of agencyactivities made it clear that very few ofthem were providing psychiatric servicesfor the more severely a¡ected section ofthe population, either in the communityor in existing psychiatric institutions. Onlytwo agencies, apart from our own, wereproviding psychiatric care through clinicsin Port-au-Prince. In the earthquakea¡ected areas outside the city, there wereno psychiatric services available. The Inter-national Medical Corps then made thedevelopment of accessible psychiatric
support and services for this group apriority.Interventions to support the acute psy-chiatric hospital included: the provision ofa sta¡ transport vehicle, a generator,bedding, patient clothes, hygiene kits, clean-ing materials and essential medication. Atthe request of sta¡, a series of twice weeklytraining seminars was organised for threemonths. Also at their request, these seminarswere then extended for eight weeks. Theseaimed to support sta¡ in evaluating anddeveloping their care and treatment prac-tices. A generator was also provided for thesecond hospital, which cared for longer staypatients. Other organisations provided foodand tents. However, in light of the continuedfunctioning of both hospitals, albeit at areduced level, we decided that furthersupport of the two institutions requiredresources beyond the capacity of an emer-gency health agency. In line with the IASC
Guidelines, we therefore prioritised the rapiddevelopment of community based mentalhealth services that would both serve emer-gency needs and decrease the demand forinstitutional care. Since a large number ofpeople with mental health problems werebeing seen in the Emergency Room follow-ing the earthquake, it was also decided toprovide a temporary psychiatric liaisonservice for the University Hospital, HUEH.A psychiatric liaison service at the Univer-sity Hospital started two weeks after theearthquake. In consultation with the hospi-tal’s Haitian medical director and theGovernment’s Department of Health, itwas agreed that a Haitian psychosocialworker would be employed to triagereferrals, supervised by an international orHaitian psychiatrist. The psychologistprovidedboth group and individual therapy,and a psychiatrist was available daily to seecomplex cases, as well as patients whomight
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need psychotropic medication. After sixmonths, as earthquake related problemsdiminished, the medical and psychiatricliaison services were gradually withdrawn.Community based mental health servicesbegan within a month of the earthquake inlocations with the greatest concentration ofdisplaced people. The model used followedIASC Guidelines and was supported byMinistry of Health o⁄cials. Mental healthclinics were integrated into eight busyprimary healthcare centres, each serving adisplaced population of between 10 and15,000. Most took place under canvass sincemany surviving buildings remained unsafe,and sta¡ and patients understandably feltsafer in the open. The clinics were locatedin the western suburbs of Port-au-Prince,and in the earthquake damaged SouthWestand Southern provinces.To address the time management problem,we suggested that mental health care beorganised in a manner similar to antenatalcare, by providing a‘mental health’clinic oncea week. At each primary health care clinic,a Haitian general practitioner was thereforereleased from general duties for half a day aweek to run this service. Thus, rather thanseeing such cases as a time consuming inter-ruption, the practitioner could give themadditional time, and more dedicated atten-tion. It also allowed for concentratedperiodsof on-the-job supervisionby an internationalpsychiatrist (one of the authors), oraHaitianpsychiatrist learning to become a workplacetrainer. Each mental health clinic, includingthe one attached to the emergency room,was co-ordinated by a community psycho-social worker, usually a previously un-employed Haitian psychologist or nurse.These were recruited as full time mentalhealth sta¡ working with patients on a dailybasis. As well as their service coordinationrole therefore, they were able to undertake
preliminary assessments, provide individualand group therapeutic activities, liaise withother community resources such as localleaders, aid organisations, and traditionalhealers, and act as the point of referral forvictims of sexual and gender based violence.Each psychosocial worker also had the taskof recruiting and supervising a dozen localcommunity volunteers who could promotegood mental health, support appropriatemourning processes, identify peoplesu¡ering from severe mental illness intheir neighbourhood, engage them intreatment, and help them access localresources. Psychosocial workers liaisedclosely with the general practitioner incharge of their weekly mental healthclinic, and were clinically supervised by thevisiting international or local psychiatrist.In addition, a senior psychosocial worker,who organised a separate training pro-gramme to support and develop the act-ivities and skills of the psychosocialworkers, managed them.A patient ¢le system was established torecord demographic, clinical and traumarelated information. In addition, teammembers were taught to use the mentalhealth categories and case de¢nitions newlydeveloped in theHealth Information System(HIS) of the UNHCR, for use by primarycare sta¡ working in refugee camps(UNHCR, 2010). We used a pilot version,which included case de¢nitions, loaned tous by UNHCR, as yet unpublished. Thecategories are based on a recommendationin IASC Guidelines (2007), and are designedto simplify the diagnosis of mental distressand disorders by primary health careworkers, so that they can identify probablepsychiatric cases.The prior failure to includeanything but the most gross mental healthdiagnostic categories in HIS systems, inmany low and middle income countries,
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has added to the di⁄culties of primaryhealth care workers giving these patientsattention and care. The categories used(Table 1) are straightforward, and easilyrecognised by health workers. They also, toa large degree, match the newly createdmental health Gap Action programme(mhGAP) priority conditions (WHO,2010b). Establishing the community servicein Haiti provided an opportunity to infor-mally ¢eld test these de¢nitions. Essentialpsychotropic medication, included in theWHO essential medicine list, The Inter-Agency Health Kit (WHO, 2006) was madeavailable in all clinics.Training played a central role in clinicactivities. For the general practitioners,the aim was for them to be able to clinicallymanage most people presenting with severemental illness within three months. Thiswas done through workplace training andattending a weekly half day teachingprogramme. Assessment involved a combi-nation of workplace Assessed ClinicalEncounters, Case Based Discussions, andan end-of-training examination consistingof Objective Structured Clinical Examin-ations (OSCEs) and an oral exam.
Health Information System (HIS) for use in huCategories
HIS1 Epilepsy/seizuresHIS 2 Alcohol or other substHIS 3 Mental retardation/ inHIS 4 Psychotic disorderHIS 5 Severe emotional disoHIS 6 Other psychological c
in major day-to-dayHIS 7 Medically unexplaineNo HIS category for: Dementia
Other, for psychiatricNo psychiatric disorde
The curriculum of the teaching programmewas based on the textbook ‘WhereThere Is No
Psychiatrist’ (Patel, 2003), IASC Guidelines,and a draft of the mhGAP Intervention Guide
(WHO, 2010b). Psychosocial workers alsoattended the half-day teaching programme,and were supervised in providing basic,individual and group interventions focusedmainly on anxiety management andproblem solving. Two part time Haitianpsychiatrists were recruited to train asworkplace supervisors and assessors of thegeneralpractitioners, so that the programmecould become independent of internationalsta¡, and therefore more sustainable.
Patients seenDuring the ¢rst ¢ve months of thecommunity clinics, a total of 431 patientswere assessed on eight sites. Assessmentsincluded a supervising psychiatrist in 65%of cases. Of the patients seen, 22% hadexperienced the loss of a ¢rst-degree relativein the earthquake, and 74% had su¡eredserious damage or collapse of their dwelling(Table 2). About half of those assessed hadseen a traditional healer for their complaint,often at great expense. By far the most
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CR, 2010)
manitarian settings: Mental Health
ance use disordertellectual disability
rderomplaints (including anxiety) not resultingdysfunctiond somatic complaint
disorders not covered in the seven categoriesr present
Number of new patients seen 201 431Total clinical consultations 356 722Mean age 30 (range 3^75) 32 (range 0.5^88)Number of females seen 59% 64%Children seen (under16) 13% 13%Loss of 1st degree relative 29% 22%Loss of non1st degree relative 12% 13%Housing destroyed by earthquake 27% 58%Housing damaged, but habitable 15% 16%Seen by traditional healer 15% 47%Assessment by GPor psychosocial
Integrating mental health into primary health care settings after an emergency: lessons from Haiti
Intervention 2011, Volume 9, Number 3, Page 211 - 224
common mental health category was‘other psychological complaints’ (HIS 6) whichaccounted for 55% of all patients seen(Table 3). These complaints were over-whelmingly of anxiety, usually focused ona fear of buildings falling, or of losingpeople close to them. Psychosis (HIS 4)accounted for 13% of patients seen andepilepsy (HIS 1) for 11%. Surprisingly only3% of patients had severe emotionaldisorder (bipolar or severe depression) andonly ¢ve cases of alcohol or other substanceuse disorder were diagnosed. Symptoms ofgrief were common, and it was often hardto disentangle what was culturally normal,from what was morbid. Concerning treat-ment, 40% received psycho education,which included anxiety management; 34%psychosocial support, usually in the form ofhelp in solving basic needs related problems;
and 5% focused counselling. Only 20%were prescribed medication.Comparing diagnoses made in communityclinics during the ¢rst ¢ve months after theearthquake (February^June), with the next¢ve months (July^November), there was a10-fold reduction of patients presentingwith minor disorders as recorded underthe HIS category 6 of ‘other psychological
complaints’ (Table 3). By contrast, severeemotional disorders increased from 3%to 21%, and medically unexplained com-plaints increased from1%to15%.Dementiaalso presented more frequently during thislater period, althoughtherewas little changein the referral pattern of other severe andchronic disorders, such as people with psy-chosis, learning di⁄culties or epilepsy.The general hospital clinic appeared to pickup a similar range of clinical problems as
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Table 3. Diagnosis of newly assessed patients (data February^November 2010)
Health Information System(HIS) diagnosis for use inhumanitarian settings:Mental health categories(probable cases)
the community clinics. This probablyre£ected the fact that large numbers ofdisplaced people in nearby city centrecamps used the hospital for primary care.However, there was a six-fold increase inthe number of patients seen with severeemotional disorders at the hospital, ascompared to primary care, during the sameperiod after the earthquake. Many of thesepatients had life threatening depressivedisorders, and were often in a state ofextreme physical neglect requiring medicalintervention. The general hospital emer-gency room received many cases of severegender based violence, sometimes withchildren as the victims. Poor security andlighting in many of the camps, as well asdisrupted community links, may haveaggravated this problem. Four particularlyseverely a¡ected victims of sexual abuse
were assessed and followed up by thehospital psychosocial worker.Concerning sta¡ training, over the ¢ve-month period starting from February 2010,140 health workers attended one of sixprogrammes of mental health seminars,each heldona di¡erent site.Of these,73werenurses and 31 medical practitioners. Therest included psychologists, health assistantsand a small number of translators. Twelvemedical practitioners completed the com-bined seminar and work place trainingprogramme, and successfully passed theassessment programme.
DiscussionThe patient information, recorded inTables 2 and 3, represent an audit of whopresented at the mental health clinics, butcannot give an accurate picture of needs
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within the community. The data does,however, give a snapshot of what people willbring to primary health care clinics in anemergency situation, and how that picturechanges over time. The signi¢cant presenceof epilepsy and psychosis justi¢ed theattention givenby the programme in provid-ing services for those with severe mental dis-orders, and is consistent with experiencesin other emergencies (Jones et al., 2009).The 10-fold drop in incidence of HIScategory 6, from 55% during the ¢rst ¢vemonths after the earthquake to 5% in thesubsequent ¢ve-month period, almostcertainly re£ects the temporary nature ofthe surge of anxiety following the disaster.These cases appear to have been partlyreplaced by cases of severe emotional dis-orders, for the most part depression, endur-ing grief reactions, and somatic complaints.This may re£ect the enduring problems ofloss, and the stress of daily life in temporaryand inadequate shelters.In terms of setting up the mental healthclinical and training programme, the IASCmodel proved to be a useful operationalframework. In £uid and insecure circum-stances, with enormous logistical challenges,it was possible to integrate a mental healthservice into at least half of the emergencymobile primary care clinics set up by theInternational Medical Corps within thedisaster hit areas.The UNHCRHIS systemalso proved to be a useful tool for trainingsta¡, and related neatly to the mhGAPcurriculum. However we had to add threenew HIS categories: no psychiatric disorder,dementia, and ‘other’ for psychiatricconditions not covered under the sevenheadings.
Dilemmas encounteredOf the many dilemmas faced in developingand running the programme, three related
dilemmas stood out: the sustainability ofthe integrated mental health/primary caremodel, post emergency in a country withpoorly developed primary health infrastruc-ture, and no history of community psy-chiatry; the possibility of unintended badconsequences; and whether it was wise toinvest in community mental health services,rather than reinforcing already establishedcentral ones.The moral case for providing local emer-gency clinics after the earthquake is clear,but should a mass disaster be used as anopportunity forWestern agencies to promotecommunity mental health services, parti-cularly when central services are so under-developed? Additionally, is it reasonable toset up amodel thatmay prove unsustainable,since it is so dependent on the continuing£ow of foreign aid, and the future prepared-ness and capacity of the Haitian governmentto take over responsibility? As far the modelof care was concerned, we felt that this wassomething on which there was an inter-national consensus, rather than beingwestern imposed clinical practice (WHO,2009). Also, the patchily provided medicalsystem in Haiti, with its heavy dependenceon private, urban based services did notprovide an ideal structure in which to inte-grate community based mental health care.As far as donor commitment goes, althoughthis has been maintained to date, it remainssomething to be advocated for in theseuncertain economic times. It will needexpensive long term institution buildingif the model is to be rolled out nationally.At the very least, we hoped to demonstrateto the Haitian government the bene¢t offree services provided through the innumer-able mobile clinics that were running duringthe emergency, and to model how mentalhealth care could be integrated into primarycare.We were involved in discussions about
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the possibility of setting up publicallyfunded primary health care, but there wasno guarantee that this would happen. Sothe question arises as to the value of trainingprimary healthcare workers for a servicethat may not be sustained, and the ethics ofproviding care free of charge when thattoo may not last. Recognising that we couldnot predict the long term direction ofplanning with elections about to happen,we reasoned that it was worth training acadre of primary care sta¡ and psychosocialworkers who could be a resource for thecountry in the longer term.All humanitarian interventions risk unin-tended bad consequences. For example,providing services to hundreds of tentedcamps inevitably creates dependency,although the continuing failure to clearrubble and build e¡ective new homes hasmeant such services have remained essential.Another important consequence is thatthe presence of a competent outside agencyproviding free medical services may under-mine local incentives to manage problemswith local resources. There was certainlyno shortage of Haitian doctors in thecountry, many having run small privatepractices before the earthquake. Indeed,the mobile emergency clinics set up by theInternational Medical Corps were sta¡edby doctors easily recruited from the privatesector whose own clinics were out of action,as well as a small number of ministry ofhealth (MOH) sta¡ out of work becausetheir clinics had been destroyed. So,although we avoided recruiting fromfunctioningMOH services to prevent under-mining public services, we may haveinadvertently underminedthe private sector.Another consequence of providing freeservices, which included free medication,was that drugs donated to Haiti foundtheir way onto the market place. We had
direct evidence, for example, of donatedpsychotropic drugs being sold to patients.All of these unintended consequences ofintervention need further evaluation toinform future practice.The ¢nal dilemma arose fromthe decision tofocus mainly on creating new communityservices, rather developing the two existingpsychiatric institutions. This decision wasmade partly in line with the principlesincorporated in the IASC guidance, andpartly onpragmatic grounds.Wehad limitedresources, and were unable to provide aservice to both displaced people, and largepsychiatric institutions. We also calculatedthat since the institutions were providing atleast some level of service, our priorityshould be to reach displaced people withsevere mental health problems who wouldotherwise have no access to treatment.Our concern, in retrospect, was whetherwe could have detected a larger numberof severely ill new patients by using ourresources to improve access to the twoestablished psychiatric hospitals. Certainly,community services are good at engagingpeople in treatment because of better acces-sibility, but there were insu⁄cient resourcesto scale them up across a metropolitanpopulation of 3.5 million people, let alone acountry the size ofWales. Additionally, thereare economies of scale in centralising, evenif some will not access the treatment. So thedilemma was, with scarce resources, couldwe have done more for the severely mentallyill population as a whole by reinforcing thecapacity of a centralist approach, ratherthan setting up a newly created integrationof specialist mental health and primary careas recommended by the IASC? Lackinghard evidence, our impression was that fewof the patients seen in the community clinicswould have attended hospital, particularlyin the more distant clinics, where we saw
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patients who had not been able to access carebefore. A hospital centred approach mayhave helped to improve both psychiatricout patient and inpatient care quality, butmay not have attracted many extra newpatients.
What lessons were learnt fromour intervention?Some things went well, and we wouldrepeat them in similar circumstances.Others went less well, and pose real ques-tions for future interventions.What worked well was the ability of theclinics to rapidly identify and treat severelyill people in the camps, providing a servicethat complemented the psychosocial act-ivities provided by other less specialistorganisations. Integrating a specialistservice with the emergency mobile clinicsundoubtedly helped with this. The super-vised Haitian general practitioners wereoften already aware of untreated psychiatriccases on their patch, and with the help ofthe psychosocial worker, were able to getthem to attend the specialist clinic. Inaddition, partly because the clinics were soaccessible (moving within the city wasextremely di⁄cult and time consuming),patients almost always came with family orconcerned neighbours. So even quite dis-turbed patients could be managed with thiscommunity support. Of course, given thelevel of social disruption caused by thedisaster, some patients had no support anddid not seek help. However, in time, the psy-chosocial worker’s ability to network withinthe camps led tomany of these more isolatedindividuals being engaged in treatment.The second thing that seemed towork reallywell was on-the-job training. Although thiswas often di⁄cult logistically, because ofsecurity or transport problems, it did meanthat supervisors had regular ¢rst hand
experience of a wide range of clinics andwere able to become more attuned to thecultural and contextual di¡erences inherentin their work, something particularlyimportant for the international supervisors.Trainees also valued the immediacy andpersonal relevance of feedback, and feltmorecon¢dent to manage complex cases. Signi¢-cantly, this training model proved resilientenough to cope with busy and often chaoticemergency clinics.We did, however, have reservations aboutone key aspect of the IASC Guidelines. Giventhe scale of the disaster, it proved unrealisticto provide mental health care in everyemergency primary health care location, asrecommended in the guidelines. Even if theon-the-job training component had beendiluted, the specialist resources needed toscale up the integrated mental health/primary care model for all the emergencyclinics serving a displaced population ofwell over a million people would havebeen considerable, and beyond the capacityof all existing medical aid organisations puttogether.Wewere also opposed toweakeningthe amount of on-the-job supervisionprovided, viewing this as an essential partof the training. Recognising this, we triedwherever possible to place mental healthclinics in central locations.Twowere in tentswithin the grounds of district hospitalsproviding primary and secondary generalmedical care, while others were in locationsconvenient enough to allow referrals froma number of nearby primary care clinics.This still left the vast majority of displacedpeople with limited, or no, access to mentalhealth care. In future disasters, we shouldpay greater attention to the setting up ofcarefully situated integrated clinics operat-ing as referral hubs, serving clusters ofemergency primary care clinics. We wouldalso employ psychosocial workers to develop
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and support this more, dispersed way ofworking.Building an e¡ective health service for thelong term remains an enormous challengefor Haiti, not least because of the extent ofinstitution building required to increase thecapacity of the Department of Health, andto train an appropriate national workforce.At present there are few resources to traincommunity mental health nurses, or tocreate a new cadre of community mentalhealth worker. There is some cause foroptimism though. Following negotiationswith the Haitian Department of Health bythe International Medical Corps, togetherwith Partners in Health, Me¤ decins Sans
Frontie' res andMe¤ decins duMonde, communitymental health was included in the draftHaitian National Health Strategy (2010).However even if long term resources wereavailable to the government, mental healthservices may not be prioritised in a countrywith a long history of undeveloped basicpublic services, which is going to be pre-occupied for years to comewith the political,economic and social repercussions of theearthquake.
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us-canada-13606720, accessed 18 September
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Bonanno, G., Brewin, C., Krzysztof, K. & La
Greca, A. (2010). Weighing the Costs of
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