Protecting children and preserving mental health in the wake of disaster in Haiti

On Tuesday, January 12, 2010, an earthquake measuring 7.0 on the Richter scale killed or gravely injured thousands of people in the vicinity of Port-au-Prince, Haiti. According to the United Nations (UN) Office for the Coordination of Humanitarian Affairs, 30 percent of the 200,000 people who lost their lives were infants and children, and over 300,000 people suffered physical injury. Most of the 250,000 collapsed buildings were residential, rendering one million families homeless overnight. Hospitals and schools collapsed; governmental and commercial buildings were destroyed. The devastation was incomprehensible.

The extent of psychological damage from the January 2010 earthquake remains unclear in a country where the mental health infrastructure was rudimentary even before this disaster devastated this impoverished nation. Some of the most harrowing stories of the destruction are those of children – alone and severely injured. Children represent one-half of Haiti's 10 million population; and aid agencies estimate that 1 million Haitian children are at high risk of ongoing physical and psychological trauma secondary to the disaster. In coordination with the Haitian government, several humanitarian organizations have mobilized to protect the safety and welfare of the country’s children....

Click below for the rest of the article.

Glen P. Davis, M.D.

Board Member, Society for Emotional Well-Being Worldwide (SEWW)

On Tuesday, January 12, 2010, an earthquake measuring 7.0 on the Richter scale killed or gravely injured thousands of people in the vicinity of Port-au-Prince, Haiti. According to the United Nations (UN) Office for the Coordination of Humanitarian Affairs, 30 percent of the 200,000 people who lost their lives were infants and children, and over 300,000 people suffered physical injury. Most of the 250,000 collapsed buildings were residential, rendering one million families homeless overnight. Hospitals and schools collapsed; governmental and commercial buildings were destroyed. The devastation was incomprehensible.

The extent of psychological damage from the January 2010 earthquake remains unclear in a country where the mental health infrastructure was rudimentary even before this disaster devastated this impoverished nation. Some of the most harrowing stories of the destruction are those of children – alone and severely injured. Children represent one-half of Haiti's 10 million population; and aid agencies estimate that 1 million Haitian children are at high risk of ongoing physical and psychological trauma secondary to the disaster. In coordination with the Haitian government, several humanitarian organizations have mobilized to protect the safety and welfare of the country’s children.

Mental Health and Psychosocial Support in Complex Emergencies

The Inter-Agency Standing Committee (IASC) – a unique forum of UN and non-UN partners – is the primary mechanism for inter-agency coordination of humanitarian assistance. Historically, the IASC has not included mental health in its agenda, and a common framework for effective coordination of mental health needs in emergency situations has been lacking.

In 2007, the IASC introduced its Mental Health and Psychosocial Support Guidelines in Emergency Settings (IASC – MHPSS) to ensure that psychological care following natural and human initiated disasters is implemented through a systematic, integrated, and multi-sectoral approach. Grounded in human rights and equity, community participation, and a “do no harm” framework, the guidelines have been a lynchpin for coordinating psychosocial support efforts for adults and children. The Guidelines build upon existing community resources to develop integrated support systems for affected populations.

In conjunction with the Haitian Ministry of Health and in accordance with the IASC – MHPSS Guidelines, the following organizations have been developing psychosocial and mental health responses for populations affected by the January 2010 earthquake: International Medical Corps, International Organization for Migration, Médecins Sans Frontières, Partners in Health, and UNICEF. Programs emphasize that severe emotional reaction following complex emergencies can be normal responses to an abnormal situation. Based on collective experience responding to mental health in post-emergency settings, initiatives aim to attenuate distress by providing psychological first aid and continuous updates to affected communities regarding relief response efforts. Regarding children and adolescents, the IASC – MHPSS Guidelines underscore that repairing emotional health is optimal in a family context with a sense of community belonging. Factors that are particularly important in the process of healing include reinstating access to basic survival needs and physical security, rebuilding systems of education, and re-establishing opportunities and safe environments for play.

Child protection and the psychosocial well-being of children have been high priorities for those involved in responding to the crisis. While the earthquake significantly heightened threats of child welfare, it is important to note that prior to the earthquake children in Haiti were already at significant risk of abandonment, abuse, and trafficking.

The FXB Haiti Child Protection Project

The Francois-Xavier Bagnoud (FXB) Center for Health and Human Rights of Harvard School of Public Health completed an initial assessment of the impact of the earthquake on Haitian youth to ensure the needs of children in the response and recovery effort. Tim Williams, MSW, Msc, Project Coordinator of the FXB Haiti Child Protection effort, reports that the group examined current systems of practice for identifying and caring for unaccompanied children, tracing children who had been separated from their families, and reuniting them with parents. They also assessed the feasibility of long-term interventions to promote the welfare and safety of Haitian children.

The FXB assessment revealed key factors undermining child protection efforts in Haiti. In the rush to provide emergency care, injured children were scattered throughout Port-au-Prince, taken to the nearest available health care facilities, and sometimes transferred to other medical centers without records. This situation prevailed for a month, during which little if any demographic information was collected at sites of care. Consequently, critical early opportunities to record, identify, and trace children and families were lost, and the lack of data impaired fundamental child-protection efforts.

The FXB group also learned that the formation of refugee settlements after the earthquake, though necessary, further exposed Haitian youth to vulnerable exploitation. By January 31, over one million Haitians in Port-au-Prince and the surrounding communes were resettled in 600 camps for internally displaced people (IDP), some of them hosting 100,000 refugees. Children, representing 46 percent of the refugee camp population, were easy targets for organized crime, violence, and sexual exploitation.

Furthermore, the aftermath of the earthquake exacerbated the practice of child trafficking in a country that has historically served as a transit of children for purposes of forced labor and sexual exploitation. Given Haiti’s unregulated borders, weak law-enforcement practices and insufficient international monitors, traffickers in post-earthquake Haiti have faced few deterrents.

Other lessons included the finding that certain post-disaster threats to child protection stem from practices that pre-existed the earthquake. For example, many families in Haiti send their children away as restavèks – a Creole word meaning “to stay with.” Economically impoverished Haitian families send restavèks to live with more affluent families in exchange for work. With minimal access to education or recreation, the 150,000 to 500,000 restavèks who serve as unpaid domestic laborers in Haiti are often subject to physical, emotional, and sexual abuse.

By tradition, desperately poor families in Haiti also place children in residential care facilities. Although the international standard is to promptly return unaccompanied children to their relatives, the restavèk phenomenon and the practice of institutionalizing children have posed challenges to adequate placement of unaccompanied youth. The team from FXB reported that many aid workers feel compelled to consider institutional placement of children as a safer interim solution, but safe institutions are hard to come by. The FXB group encountered several hospitals where unaccompanied children who had been medically cleared were not being released for lack of a safe discharge plan. While representatives from orphanages visit camps and hospitals daily to assume care for unaccompanied youth, the FXB group found no effective mechanism for distinguishing safe residential care facilities from fronts of trafficking.

Even months after the earthquake, the FXB Center maintains that urgent needs in Haiti must be met to protect and forestall further abuse of children. Regarding the adoption of Haitian children, child protection specialists assert that an improved system for tracing children and protecting borders must first be implemented to reduce the risk of removing children from their families of origin who would care for them if given the means to do so. All aid workers in Haiti should receive training in child-protection norms and be educated about the prevalence of child abandonment, abduction, and trafficking. Child protection basics should be implemented such[S1]  as identification procedures and record keeping, reestablishment of educational opportunities, and creation of child-friendly spaces. Local government and law enforcement institutions charged with child protection must be strengthened. Family-tracing procedures, border control, and stringent oversight of orphanages must be enforced. The FXB team concluded unambiguously that the safety – physical, mental, and social – of the children of Haiti remains in great peril.

The Partners in Health Experience

Partners in Health (PIH),  the Boston-based non-governmental organization (NGO) co-founded by Paul Farmer, M.D., has worked to meet the medical, social, and emotional needs of people in Haiti for more than 20 years. Since its inception in 1987, PIH’s programs have grown to span the globe, but the community-based health project in Haiti, known as Zanmi Lasante ("Partners in health,” in Haitian Creole), is PIH’s oldest and largest. In response to the earthquake, Zanmi Lasante has worked to support and mobilize its 5,000 Haitian employees at ten Ministry of Health hospitals and community clinics in the Central Plateau and Artibonite regions of Haiti. By mid-March, the Zanmi Lasante internally displaced persons IDP clinics alone had cared for 35,000. Additionally, Zanmi Lasante has served 75,000 Haitians within four camps for IDPs in Port-au-Prince.

Giuseppe Raviola, M.D., child and adolescent psychiatrist at Children’s Hospital Boston, serves as the director of Mental Health and Psychosocial Services for Partners in Health. According to Dr. Raviola, prior to the earthquake the Zanmi Lasante psychosocial programs focused primarily on socioeconomic, educational and psychological needs of children and families affected by HIV/AIDS and tuberculosis. Since the earthquake, Zanmi Lasante has mobilized more than 50 Haitian staff (17 psychologists and 35 social-community workers) to care for the mental health needs of children and families, both in the IDP camps and rural areas.  Zanmi Lasante plans to train hundreds of community health workers in child risk assessment and protection. Curricula have been developed to help them understand the spectrum of responses to natural disasters among children, and to recognize and evaluate mental health problems in children and adolescents.

Dr. Raviola also reported that Zanmi Lasante has been working with the Haitian government to quantify the number of children residing in IDPs and collect information on the location and school status of displaced children in rural areas. Father Eddy Eustache, director of Mental Health and Psychosocial Services for Zanmi Lasante in Haiti, has developed culturally-sensitive programs to combine mourning and religious ceremonies with psychoeducational curricula implementing basic concepts of psychological first aid.

Organizations such as Zanmi Lasante are moving forward in the current crisis not only with an appreciation for the risks and dangers facing children affected by the earthquake, but also with a commitment to protecting children and preserving mental health as Haiti moves forward.

Lynne Jones, OBE, MRCPsych, Ph.D., a British child and adolescent psychiatrist and Senior Mental Health Adviser of the International Medical Corps, has eloquently contextualized mental health care in disaster situations such as the earthquake in Haiti based on her extensive field work in disaster mental health settings.  “Paradoxically,” Dr. Jones has written, “in a world with 24-hour globalised media and short attention spans, crises such as wars and disasters might be opportunities for development when governments and international actors suddenly become aware of needs that have been neglected for decades.”

Glen P. Davis, MD recently joined the Board of the Society for Emotional Well-Being Worldwide.  An Adult, Child & Adolescent Psychiatrist in New York, NY, Dr. Davis also serves as the John E. Schowalter, M.D. Member of Council of the American Academy of Child & Adolescent Psychiatry. Prior to medical school, Dr. Davis served for three years as a rural health educator with the United States Peace Corps in Burkina Faso (West Africa).

References

Balsari S et al. Child Protection in Haiti: Post-Earthquake Needs Assessment. The François-Xavier Bagnoud Center for Health and Human Rights Harvard University. March 2010 www.harvardfxbcenter.org/index.php

Bell B (2001). Walking on Fire: Haitian Women’s Stories of Survival and Resistance. Cornell University Press

Inter-Agency Standing Committee Mental Health and Psychosocial Support Guidelines in Emergency Settings. Accessed March 24, 2010 at www.who.int/hac/network/interagency/news

Jones L (2009). Severe mental disorders in complex emergencies. Lancet 374: 654–61