Dr. Reginald Fils-Aime is a Haitian physician who from 2010-2012 directed the Multidrug-Resistant Tuberculosis program in Haiti at Partners In Health and Zanmi Lasante, our sister organization in Haiti. He began his career in mental health after being inspired by the change he saw in patients through treatment with psychotherapy, medication, and social support following the country’s 2010 earthquake.
Dr. Fils-Aime has led efforts to bring mental health care into the community-based health system supported by PIH and ZL, in partnership with the Haitian Ministry of Health. He entered the Masters in Medical Science in Global Health Delivery program at Harvard Medical School in 2014, with the goal of returning to Haiti to build teams and improve systems to address health needs in the community. Here, he reflects on his work.
Mental disorders cause the same disasters in Haiti that they do in other parts of the world. When people think they have or a relative has a mental illness, they look for solutions for it. They turn to religion and to traditional healers, which are often more familiar and trusted to them than the health system, but they usually come to the hospital after, in my experience.
Most people in Haiti tend to attribute mental illness to supernatural causes, and some believe that mental disorders can be transmitted to other people. For our work, this means that staff in hospitals may be more reluctant to approach a mentally ill person. For example, some people believe that if a moun fou, a psychotic person, hits you, you should hit him or her back or you might become “crazy” too.
But working in mental health gives me hope that things will get better. One reason is because of the values of the Haitian people, the sense of community cultivated in the rural areas. We are all family in the rural area. Although rural poor people are overwhelmed by all kinds of problems, they still want to help their relatives, their neighbors, and others.
Working in mental health gives me hope that things will get better.
At Zanmi Lasante, we are treating mental disorders at the primary health care level and in the community, rather than through institutionalizing mental health patients in inadequate, locked facilities far from their families. To make mental health part of the primary health care system, we train all types of health providers to identify people and help them receive care for their problem. We train and employ community health workers as key participants to educate, screen, assess, refer, follow up, and support people in their own communities. We train and employ psychologists as central providers, as mental health leaders and advocates in our health facilities. (Learn about one tool we use in Need to Know: Screening for Depression in Haiti.)
We have also trained all the social workers at Zanmi Lasante’s clinics, and we collaborate with general practitioners, other doctors, and nurses to ensure comprehensive care for our patients. We try to organize each provider’s competency around the patient, for the patient.
With this system, we are receiving patients and treating them humanely and efficiently for mental disorders ranging from mild to severe. At University Hospital in Mirebalais, besides the community and outpatient services provided by our team, we have hospitalized several patients who were severely ill and risked harming themselves or others. We were able to hospitalize these patients in collaboration with physicians, nurses, and other staff from the emergency and internal medicine wards.
I believe what we are doing now is something that will work well in other parts of Haiti, both in the communities and in the departmental hospitals. Knowing that gives me a lot of hope for mental illnesses in Haiti.
We started this type of mental health care in Cange and we’re systematizing it now, and it’s an innovation in Haiti. As with most innovations, there is resistance to it. The biggest challenges are lack of structures and systems to treat mental illnesses, a lack of trained human resources, the need for political commitment and financial means, and the social perceptions of mental illness, including stigma.
Some relatives of mental health patients want to leave the hospital because of the disdainful, stigmatizing looks of the other patients and their families, or because they feel stigma even from some members of the staff. We handle these situations by talking to people and explaining our understanding of the disease. We try to help them with their own anxiety and fear of the disease. The University Hospital team believes that when we are treating a patient in the wards, we also have to treat the anxiety surrounding mental illness, including the fear of the staff and of the patient’s relatives who are overwhelmed by the disease.
We are trying to understand and appreciate the community and individual understandings and approaches to mental illness in the context of all their other problems. We listen to them, and we engage in productive dialogue with them. This is how we are striving to build an adaptive and sustainable system to humanely care for mental disorders.
We have to act on several fronts at the same time, but there is a lot of hope because we are finding more people very enthusiastic to help mentally ill people. Each patient we treat lessens the skepticism in the minds of some staff who didn’t help only because they didn’t know they could.