By Kent Ravenscroft, M.D.

IPI Emeritus Faculty

Saturday came around fast. I had to stand up in front of local Haitian IMC clinic doctors and nurses, and talk for 5 hours about the psychosocial impact of what they and their patients had been through.  As I’ve said, public speaking and lectures are not my favorite thing.  I spent from 4 to 5 am floating on my air mattress, dealing with my anxiety.  Into my mind came the words of Maitress Erzulie Grand Freda, who had told me, as I left Haiti 50 years ago, that I would be successful if I worked hard, that maybe someday I would come back to visit and help her people in Haiti.  Thinking of her words and feeling encouraged by my association with the great IMC staff, I took heart, found my courage, and fell back to sleep, until 5:45, when the cock crowed for me.

I had come out to Petite Goave on the southern peninsula to start up our Haitian psychosocial training program here.  We drove to the Royal Beach Hotel for my first all day workshop, to be on Mass Trauma, Loss, Grieving, Front Line Mental Health Work, Treatment, Triage, Symptoms, and Major Mental Illness.  PTSD, though popular with the press and the world, would be a small part of it, since statistically, surprisingly, it is infrequent in mass disasters, if aid and care are given right.  We would cover the needs of patients with pre-existing conditions epilepsy, mania, severe depressive disorder, and chronic schizophrenia who lost their medicine and psychiatric contact because of the quake, and address new first breaks caused by the tremors and the scarcity of outpatient and inpatient psychiatry.  We hope to leave a legacy of psychosocially competent front line Haitian family practitioners when we leave in two years.

There were 12 Haitian doctors from our 5 clinics, 19 nurses, and others from Notre Dame hospital, and 5 from Croix Rouge with whom we have liaison.  It went fairly well.  I even spoke a little Creole to the group when the translator had trouble with my medical English and concepts. I did a group exercise teaching relaxation and imagery techniques to interrupt cycles of anxiety and repetitive thoughts, and then while in the relaxed state, had them visualize where they were when the earthquake struck, helping them recapture and work on their own inner experience so as to increase their emotional availability to each other and their patients. I stressed cost-effective front line stress reduction group sessions that nurses would lead for people they would identify – groups like the one I was modeling.

I had them form pairs and tell each other about what they had been through, and then used their own thoughts and feelings to illustrate the symptoms and expectable phases of recovery for those without psychiatric diagnoses.  We talked of acute stress symptoms, and how rare chronic serious post-traumatic stress disorder is, and how early intervention on the front line reduces its occurrence drastically.  Without that support in war zones and earthquakes like the one in Haiti, PTSD results from seeing and dealing with dead bodies, and rape, abuse, and violence.

The workers told me that they felt guilty about the long lines ever day and the brevity of their problem-focused encounters with each patient.  I reminded them that their Haitian patients are used to waiting for care.  And in this case they will get care like they had never had before.  Even waiting in the clinic, being near their doctors, and knowing the Clinic is there for them, is helpful.  They deliver care in open tents with all watching, and the word gets out that help is there.  I said that they should never underestimate the importance of using themselves as a powerful part of the healing.  By their presence and their manner of caring, the front-line workers become a transference object of great importance for the camp and village.

I stressed the importance of their presence at the camps and destroyed villages.  I reinforced the impact of their caring, their laying on of hands, their quick but careful exams, their mental health first aid, and triage.  As front line workers, their work and reassurance gives hope and momentum to recovery for this impoverished, yet strong and resilient Haitian people. I reminded them of resilience, and advised them not to over pathologize what they see. I emphasized the need to see their patients’ (and their own) weird thoughts and feelings as normal responses to abnormal experiences, and to set them in the context of the normal, expectable stages of mass disaster recovery.  That’s the way to help their patients not to get stuck and become chronically symptomatic.

Once they felt comfortable with me in discussing the needs of their patients, several nurses and doctors shared their personal experiences of losing family members, seeing their houses destroyed, and living in tents outside their houses.  About a third of them had been affected.  When the topic of tents came up, I noticed two nurses looking down and huddling privately.  I finally asked if they could share what was going on.  With some embarrassment but plucky honesty, one of them confessed she didn’t even have a tent yet and was living outside with family members in one of the camps, grateful the rains hadn’t come yet, and proud she made it to the clinic every day to work, somehow looking clean and kempt.  The clinic was clearly a beacon of hope, care and support for her.  And her own experience gave depth and meaning to her work.  It raises the question:  “Who takes care of the care takers?”

One young doctor came up to me afterward, doubtful about the purpose and usefulness of the group exercise.  When I explained that it had to do with taking care of yourself as well as your patients in times of trauma, his eyes rimmed with tears and he told me about pulling children, some dead, some gravely injured, from under crumbled concrete slabs in the house next to his after he and his kids got out safely, before both houses collapsed.  I’ll be working with him in one of my weekly clinic rotations.   I was deeply moved by my experience wit him and with the group in general. The workshop certainly broke the ice for me, and I hope for them.  Now I am poised to go out and work alongside them.

It seems tents are now in short supply in Haiti and there is still great need.  We have enough tents in our privileged IMC ‘camp’.  We are well taken care of, mostly.  So I have a tent that I am not going to be using.  My extra tent was a gift from a friend who sent me off with a lot of camping stuff, urging me to give it away when I left, bless his soul.  So I plan to give it quietly to this nurse when I go to her clinic, secretly so as not to stir up envy, or a perception of favoritism by IMC.  But that other nurse huddling with her may be in the same plight.  So I have sought a more systematic solution.  I asked Stephanie, my NGO administrator if she can get tents for our clinic workers in need. I don’t want to wait on bureaucracy, but Stephanie seems to make mountains melt for her people.  She’s my kind of NGO person!

My only complaint about Stephanie is that she wouldn’t like me to visit my old field site because of security concerns over the increasing risk of abduction. She said that one abduction can cost an NGO $30,000 to $50,000, and she emphasized that this would mean that hundreds of refugees would have to go without food and care because of the wasted funds.  There was something strange about how she tightened up and how guilty she sounded, and how she used the image of starving refugees to persuade me not to go.  I learned that she had been abducted for 25 terrifying days in Darfur, before negotiators got them to release her.  But all she seems to feel about that, besides wanting to protect us, is terribly guilty about how much she cost IMC for her ransom, and the loss of money for care of the people in Darfur.  She has a lovely amulet she wears every day, given to her in gratitude by her people in Darfur.  I find myself tearing up again as I write this:  I have such admiration for this woman.  Stephanie said she felt she could probably get some tents for my nurses in the next week.

Speaking of Stephanie and tents, just the day before my workshop I had visited a clinic called Beatrice, at the top of a high hill, with a tent city surrounding a small village.  We also visited Petit Guinee, a destitute and now ruined seasoned village, and Trois Soeur, a tent city around a monastery.  Later that day a huge wind came up, and when I got back to the staff residence, I discovered that the big tent covering the Beatrice Clinic had blown down, with everyone in it.  Stephanie was frazzled because she had been called, as usual, to rescue the situation, and had spent the afternoon putting the tent back up with the staff.

After my workshop, I treated myself to a Haitian lobster dinner at the Royal, and two Barbancourt rum and cokes.  I enjoyed the ‘Strict Badou,’ a jazzy, professional Haitian group, with appropriately strong island flavors.  I slept well last night.  Even the roosters failed to rouse me.  Today is a day of rest, and a chance to write.  I made an omelette for me and Stephanie, and gave my novel to Peter who was complaining about nothing to read.   So that’s it for now, except for preparing my materials for my first clinic tomorrow.  I look forward to beginning my clinical teaching and training, though I’ve already begun to worry a little about my lecture in Port-au-Prince at the Mars et Klein Psychiatric Hospital next Saturday, possibly on Adolescence.  I’m all prepared for an Eating Disorder lecture, with slides, but somehow that doesn’t feel quite right for down here.  Anyway, type A is interfering with my day off.   Talk to you later.

Back in Touch Next Week

By Kent Ravenscroft, M.D.

IPI Emeritus Faculty

Fifty years ago when I was 20 I did my anthropology fieldwork in Masson, named for the remains of an old French plantation. I would periodically take a break, hop on a brightly colored Tap Tap or small camionette, and head back to Port-au-Prince to join the Richardot family.  Jean Bleyfus Richardot was head of the United Nations Economic Commission to Haiti at the time, and his lovely daughter, Caroline, had caught my wandering eye.  Her gorgeous mother was not far behind.  We’d go up to the grand Petionville Country Club, swimming, attending a posh cocktail party, swarming with the elite, Haitian military brass and politicians, and NGO officials.  The place would be filled with glittering jewels and conversational gems, awash with five-star Barbancout Rum and festooned with Bougainvilleas.  Things were different then.

Today, I awoke early, knowing for whom the cock crowed, and, with heart in throat, traveled up to Petionville, not with the Ricardots but with Dr. Peter Hughes, a fine Irish IMC psychiatrist, and not for leisure, but to visit our mobile clinic, staffed by Haitian nurses and doctors, and our medical and nurse volunteers.  We turned into the familiar gates of the Petionville Country Club, the metal letters of the name dangling from loose screws.  We were confronted with a jungle of military and NGO vehicles, gun-toting marines, blue-scrubbed doctors and nurses, and Haitian vendors all plying their trades.  I looked over at the tennis courts.  One of them was covered by a behemoth tent housing a dozen small tents, a small orphanage compound, and supplies.  Two courts were pock-marked by tire tracks leading to the back tennis courts where army vehicles and supplies were stored.  With apprehension and curiosity, I walked out onto the Club terrace.  I saw cracked columns, and huge jacks holding up cement cross beams, camo partitions and windbreaks obscuring my view.  The NGO’s (non-governmental organizations) including IMG, were gathering on the left, and the army was on right.  The army guys were buff in their camo fatigues, lounging in front of a huge TV watching March Madness.  Zombie-like I walked forward to the edge of the terrace.  I looked over the empty pool at the withering Bougainvillea, bearing faded red flowers.  I could just see, over the brow of the hill, three NGO tents, their names emblazoned on the sides, and a few army vehicles.  With its panoramic view of Port-au-Prince and the mountains shimmering in the mid-day heat, I could still see the Club’s former grandeur.

Peter, Kettie, our superb Haitian psychosocial nurse, and I had a pre-arranged rendezvous with a Canal 24 television reporter and her video cameraman.  We were their entrée into the camp below, and they were possible resources for donations to Haiti Relief.  And long term relief is essential.  We walked together over the brow of the hill.  I caught my breath at the sight of the multi-colored mosaic of a tent city now housing 40,000 Haitians.  Following the contours of hills and ravines in all directions, the city was displayed like a Cubist painting.  Our group clinic is nestled in the middle of this tent city. NGO psychosocial care and health groups are scattered throughout, and others are placed strategically around the periphery.  We threaded our way down into this warren along dirt alleys, zigzagging our way between tents, Haitian blankets spilling out of their tents onto these walkways, kids playing, mothers nursing and cooking, and men and women selling their wares every few feet.  We met with civility and curiosity at every step, and I often stopped to say a brief hello in Creole, and got a smile and polite hello back.  I took a picture of two girls combing the hair of their Barbie-like dolls, and a bunch of boys with kites made of refuse, one flying quite high.  And then there was the long string trailing behind a little boy with a piece of red refuse at its end.  I caught on quick: He had a red puppy on a leash.  I yelled when Peter almost stepped on it, saying, “Watch out for the puppy!”  The boy and his friends cracked up.  The child psychiatrist in me was on the look out for resilience and strength, and not just tragedy.  We spent several hours at the clinic seeing psych patients, teaching the young Haitian psychiatrist and learning from him about front line work.  We were in awe, as we watched the other doctors see 70 to 100 patients each couple of hours.

I kept thinking back to the Petionville Club.  Its transformation was mind boggling.  It stirred confusing emotions in me, sadness, respect, appreciation, and hope mingled with anger at the cost of the earthquake, Haiti’s impoverished condition, and its smoldering future.  If the Haitian government, despite all the help, takes too long to pull itself out of disarray, there will be trouble. The OXFAM people are worried about various scenarios in Haiti, any of which might result in the complete collapse of government authority and a surge of wide-spread, violent civil unrest.  I heard from a young friend who is studying international relations that the consensus is that the situation may well deteriorate quite rapidly over the next month as the country descends into chaos and a violent upheaval takes hold.  Her father wrote to me, “You may have seen the beginning with the kidnapping incidents, but it could get a lot worse.  Do you have a weapon?”

But my time was up in Port-au-Prince.  So I packed up early two days ago.  I am actually beginning to miss my little tent which had come to feel like home, all cozy and organized.  Even a rooster came clucking and crowing behind my tent to wish me goodbye.  I took pictures of Pierre and Carmen and Alice who fed us ‘di ri ak poi rouge’ (rice and red beans), ‘di ri ak jon jon’ (rice with french peas and jon jon flavoring), overcooked chicken, and ‘banan peze’ (flattened fried rounds of Plaintain), among other things.  We spoke Creole together which pleased them.  I said my good byes to staff, and followed my driver to the IMC Rangerover.  I had thought the drive to Petit Goave on the Southern peninsula would take 4 or 5 hours.  He told me 2.  Just driving to the Gressier Clinic the previous day had taken 1 and 1/2 hours.  So, I was dubious.  We wound our way down the mountain past the chaos of UN yellow tee-shirted Haitian conscripts working to clean the debris from the sides of the roads, where everyone had piled the debris of their shattered houses.  There were more bulldozers and dump trucks lumbering about, often ancient Mack trucks from the ’50’s kept alive by canny Haitian mechanics.  We crept through Carrefour intersection, amidst teams of brightly colored tap taps, camionettes, and huge camions, each with their own pictures hailing Jesus and pop stars, with Grace a Dieu, and Jesus Sauve Tous, written on the front.  The good ship Comfort, all white with a red cross, had departed.  The road was flooded and rutted down 12 inches deep.  The Marines who built it in the 30’s would be aghast.  We drove past the mix of standing, tilting, and crushed houses that I had seen when I went to Gressier Mobile Clinic yesterday.  I recalled again the volunteer doctor who had talked of seeing the sparkling azure blue see and waving palms, beyond the few standing houses.  He felt it was all beautiful, until he realized that he was passing a huge graveyard of unearthed bodies on either side.

We got to Gressier in the expected 1 and 1/2 hours, and shoved on.  The road improved, and my driver began to rocket along, careening around curves, even pulling out around tap taps and huge slow moving Camions, barely pulling back in after a kamakazi chicken game with a daredevil coming the other way.  We had had a security meeting the previous night about the abducted volunteers from another organization (I found out that morning they had been returned alive — for a price), and in passing they commented that if our drivers scared us, or took chances, we should ask them to slow down.  I kept quiet, being used to the Haitian driving and wanting to get there fast.  Unwisely, I kept taking off my seatbelt to take pictures on either side, at one point thrown forward as the driver came to a screeching halt in front of a gaping jagged hole, the Zeus mark of the earthquake.

Finally we crossed the Momance River, and my heart pounded in my chest.  We were at Brache, where I used to get off my Camionette to walk toward my field site at Masson on the blue Caribbean.  It was vastly different.  I don’t mean just the fifty years of build up, including Leogane’s encroachment.  When I heard about a guy from Masson collecting money, I had been dubious.   How could mud huts held by wattle be affected by the earthquake?  But when I saw the devastation, I gasped and my eyes welled up.  The driver slowed down to see what was wrong with me.  He had no idea I knew any Haitians, especially way out in the boonies, but there I was, a tear-rimmed shambles.  I let him know everything about the friends who were gone or missing, and then he told me what had happened to his family.  He had lost his aunt and his house.  After our sad sharing we spent several minutes together, leveled by the earthquake. I told him I wanted to visit the families I had studied.  I wanted to bring them photos I had taken of them as children, and of their parents and grandparents, as well as a nice gift of all my camping stuff and clothes I am using, and (though not mentioned to my driver) a big gift of American cash I had brought with me.  And in Haiti, the greenback is still king!  And I must say, I see USAID tents and tarps everywhere, and the military standing tall and beautiful.  Those yellow t-shirts along the way make me smile.

To my surprise, as we crested a hill, the vista of Petit Goave stunned me. From the pass we could see a majestic bay, with large ships, and a few scattered sailboats curving into a harbor, cradled by hills and mountains, still fairly green.  It was breath-taking, a part of Haiti I had forgotten, since I saw it only briefly on my quick trip my last summer.  Once we entered Petit Goave, my smile faded as I saw the crumpled buildings beginning, and the myriad clusters of tents — blue (UN) and white (USAID) — and other hews of the rainbow from other groups, from Tibet, and Japan, and Mexico, and France, and Canada.  The international care and gifting is amazing.  I was just told that over 900 groups are here right now.  And there are these incredibly ramshackle constructions everywhere, makeshift from every salvageable piece of debris, made by the poor not receiving aid.  It seems 3/4 of the population is living outside.  That’s the incredible short of it, though the long is more complex.  People are living outside of their houses because they are destroyed, because they are too dangerous, because they are under reconstruction, AND because the inhabitants are terrified of aftershocks.  In China many villages in quake-prone areas keep deer penned outside the village with a person dedicated to watching them.  Deer are incredibly sensitive to the slightest ground tremor — great for avoiding approaching predator, AND pre-shocks of approaching earthquakes when the tectonic plates begin slight shakes as they build up for the big one.  Well, people here are now as sensitive as deer.  In a second, I’ll give you an example.

We first pulled up to a gated beach side hotel, which looked promising, but then we found out the residence where I was staying was elsewhere! Off we went, down the dirt side- road of the National Highway filled with small or shattered houses at first, then a few larger gated houses, until we reached one with a guard.   The drive had, indeed taken just over 2 hours, though I had my eyes shut for most of the last of it.  Except for taking in the view from time to time. Stephanie, a French Canadian, the cute young director of our IMG unit, greeted me, her cell phone glued to her ear.  She was doing a million things, full of energy and excitement.  Lunch was underway, which was quintessentially Haitian, except for a veggie stew because our young director is vegetarian.  Tom, a Kenyan evaluation guy from Port-au-Prince, Jattu, a black Russian and English speaking clinical assistant, and Joanne, our Psychosocial Haitian assistant were there.  Right away, I discovered the nurse clinician to be appointed for my team had decided not to take the job, and so I was evaluating resumes for that position.   Stephanie asked if I wanted to stay there, or at the Hotel where she had a room for me.  Stupid me, now a tent addict, I said I’d stay there, close to the staff action.  Well, at about 6 o’clock everyone disappeared.  Stephanie went out and the others departed for the hotel.  I deployed myself in a tent 4 times the size of my homey pup dome tent.  Now down at sea level, instead of up on Petionville, it was HOT.

The weather has been perfect, beautiful blue skies since the third day, no rainy season yet.  But hot, and HU-MID!  The exertion of going to bed works up a sweat, and my exercises make me drip, but my back makes me stretch.  One good thing, I have lost a LOT of weight, so much that I can get my knee not just to my chin, but almost to my ear.   But I’ll tell you why.  Lunch was also dinner for me, the one consumer.  When Stephanie returned, she said she had already eaten.  Not exactly a mother hen.  So I ate what I could, the salad having been sitting out all day, BUT with beets in it, which were irresistible to me, though where the hell did they find beets?  When Stephanie stopped gyrating, she told me that another team had just been added for me to teach, and also that there had been another kidnapping of an NGO volunteer, up at the other end of Haiti in Cap Haitian, where Henri Christope the liberator  of Haiti had his chateau Sans Souci, and his Citadelle, with canons that could make the earth shake and carry 20 miles to the bay, should the French return.  So we were in tighter lock down, and I was informed I couldn’t go out alone.  I was feeling trapped.  The ground was shifting under me.  I was worrying about preparing an all day workshop in two days and organizing and implementing their master clinic plan — not good for a type A guy in retirement.

While I was talking to Stephanie, I saw her jump and start to bolt.  “What’s up?” I said.  “Didn’t you feel that?” she said.  “What?”  “That small aftershock!”  Frankly I didn’t feel a thing, but today it was all people could talk about, that some people were eating dinner at the hotel while the other half were leaping up and running out lest the thing continue and the ceiling cave on them.  Some people, I would say, now a little hypervigilant, turned into a bunch of post-shock deer.  But then again, if I had been through what they have been through I would be hypersensitive and out the door.  Anyway, I had awakened early, so I was eager to email my wife Patti, or hopefully reach her on Skype, so I went to the internet only to find out it was down and had been down all day.  Stephanie went out to do a security briefing.  So there I was – left, alone, having to prepare my talk, which was not my favorite thing to do, lonely, cut of from Patti, no real food, no company, and a strange new tent to sleep in.  Well, I frittered around for about an hour, reviewing things, then hit the hay, or, rather, the air mattress, once again feeling swamped and disorganized.  Where was my psychiatric side-kick, Peter, when I needed him?  I gave him a buzz, told him I’d lined up four nurses for us to interview when he arrived, and he said great.

I was amazed how disabled I felt with no internet, but sleep beckoned, except that my friendly roosters were replaced by the late night carousing of radios of some nearby Haitians and NGO workers. And yet, all was music to my tired ears, as I thought about the mission I was on for all my Haitian friends.  I would only have to be in the altruistic humanitarian mess for three more weeks.  I could stand it, and give as best I could.  My time was now here.

Back in Touch Next Week