A patient of the Haitian government's Mars and Kline psychiatric… (Eitan Abramovich / AFP /…)
Reporting from Port-au-Prince, Haiti — In a sweltering annex behind the General Hospital, inner demons stalk in plain view.
In one cramped room, a 58-year-old woman rocks rhythmically on a folding chair and recites Psalms one after another, her mouth curled up in a faraway smile. In another, a young man describes how his heart takes off without warning, thumping like a runaway train the way it did that terrible afternoon.
Not all the hurts from Haiti's earthquake can be seen. The Jan. 12 temblor, which the government estimates killed 300,000 people, also exacted a toll on the psyche of survivors. The damage is still emerging months after many of the physical wounds were patched up.
An untold number of Port-au-Prince residents are suffering anxiety or feeling panic at the slightest movement that suggests the earth is shaking. Others have fallen into depression. For people who had underlying mental illnesses, the shock and grief have been severe enough to trigger a variety of disorders, including schizophrenia and mania, mental health workers say.
The poorest country in the Western Hemisphere was never an easy place to live. Recent months have poured more stress on families, many of which are living on the streets with no money, unsteady supplies of food and a future that on many days appears to be a fearsome void.
"People were pushed over the threshold," said Peter Hughes, a London psychiatrist who heads mental health efforts in Haiti for the Los Angeles-based International Medical Corps, which has three psychiatrists working here. "The earthquake changed everything."
Hughes and his colleagues working at General Hospital have seen 200 patients referred from the emergency room for a variety of mental problems. The quake was an aggravating factor in most of the serious cases and the cause of what Hughes calls "earthquake anxiety," a not-unexpected reaction often marked by insomnia, racing pulse rates and a lingering fear of going indoors.
A 34-year-old woman lying in bed in the main hospital insists that her legs are paralyzed, though they work fine. Hughes said the "conversion disorder" stems from stress turned into physical symptoms.
"We don't even argue with her about it. She won't believe us," Hughes said.
Although medical workers say Haitians have handled the calamity with remarkable resiliency, the nation was ill-prepared for a deluge of mental health problems. Its Public Health Ministry employed only nine psychiatrists, one for every million residents. There were fewer than 20 psychiatrists in private practice.
The capital's 50-year-old government-run psychiatric hospital, Mars and Kline, is a bleak bunker of chipped paint and grimy tile floors where 60 patients sleep in padlocked enclosures without beds.
On a recent day, a dozen patients languished behind bars in a sun-scorched concrete courtyard fouled by human waste. Half wandered without clothes. On a wall, someone had scrawled "Death Row," the name patients gave to a corridor through which many escaped during the earthquake. The hallway is decorated with faded, childlike drawings of fruit and Santa Claus.
Louis Marc Jeanny Girard, a psychiatrist who has served as the hospital's medical director for 10 years, said Haiti has never treated mental illness with much care. Often, he said, people suffering psychoses were dismissed as being in the grip of the "mystical."
"They never take the mental health issue seriously," Girard said. "They take AIDS and things they can see visually and give them more value. They always put this problem at the end."
But Girard and other mental health professionals say this may be the perfect moment to fix the inadequacies.
Foreign organizations have begun discussions with Haitian officials on the outlines of a decentralized mental health system that would rely on grass-roots diagnosis and care across the countryside.
Community mental health workers would be trained to refer patients to local clinics. Those with serious problems would be referred to psychiatrists. A similar model has been employed for HIV treatment.
"What we want to have is a system where mental illnesses will be taken care of on the ground," said Eddy Eustache, a priest and psychologist who works here with Boston-based Partners in Health. "It is an opportunity to admit that little has been done for mental health. The government has to do something, and I think they are on the right track."
It is too soon to know how many workers would have to be trained or how much such an approach would cost. It seems clear, however, that much of the load would continue to be shouldered by groups such as Partners in Health, which is running a pilot project in Haiti's central and coastal regions.
Since the quake, the group has trained and hired 17 psychologists and 50 social workers. Partners in Health plans to hire 600 community health workers to bolster a force of 2,000 already tending to nutrition and child health issues to improve detection of depression and stress.