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Haiti: After the Earthquake

by Paul Farmer. New York, PublicAffairs, 2011, 456 pp., $27.99.

Reviewed by Frederick J. Stoddard, Jr., M.D.
Am J Psychiatry 2012;169:435-436. doi:10.1176/appi.ajp.2011.11101601
View Author and Article Information

Boston, Mass.

The author reports no financial relationships with commercial interests.

Book review accepted for publication November 2011.

Accepted November , 2011.

The earthquake in Haiti on January 12, 2010, killed more than 300,000 people, injured and psychologically traumatized many more, and left tens of thousands homeless. Since earthquakes resulting in this scale of destruction occur primarily outside of the United States, such devastation is less familiar to those in the United States, who know more about disasters that are more common within their own country, rather than in low- and middle-income countries (1). Paul Farmer, M.D., a university professor at Harvard and a founder of Partners In Health, serves as the United Nations Deputy Special Envoy for Haiti, supporting President Bill Clinton, United Nations Special Envoy for Haiti, in disaster relief. Throughout his career, Farmer has been dedicated to providing and improving the medical care in disadvantaged countries, particularly Haiti and Rwanda, through Partners In Health. He is a role model, both here in the United States and elsewhere, for compassionate medical students and physicians who wish to use their medical skills to achieve altruistic goals in developing countries. Because of this, Haiti: After the Earthquake, which details the effects and sequelae of the earthquake in Haiti and is written by Farmer and his colleagues, deserves the attention of medical students, residents, psychiatrists, and other mental health professionals as well as all physicians.

After the first 247 pages, the book's collaborators add their voices with additional sections. They include Farmer's wife, Catherine Bertrand Farmer, as well as Edwidge Danticat, Michèle Montas-Dominique, Nancy Dorsinville, and Didi Bertrand Farmer in a section on women; Louise Ivers, Evan Lyon, Dubique Kobel, and Naomi Rosenberg, who authored a section titled “Doctors”; and Timothy T. Schwartz, Jennie Weiss Block, and Jèhane Sedky, who authored the concluding section titled “Humanitarians.” Their voices resonate with that of Kent Ravenscroft (2), a psychiatrist who went to Haiti with a United Nations group to provide acute psychiatric care and to help train doctors in sustainable psychiatric assessment and care after the earthquake.

Does this book directly address disaster psychiatric care in Haiti? No, it does not, except as medical care for those acutely suffering in the earthquake's aftermath. In this regard, the text points out goals pertaining to care that we psychiatrists share. However, it is helpful to also know about basic sources, such as the Textbook of Disaster Psychiatry, by Ursano et al. (3), and the practical disaster psychiatry handbook for primary care clinicians edited by Stoddard et al. (4). The mental health implications of the book are readily apparent to individuals who work closely with surgeons in the care of severely injured patients, to those who care for children and adolescents, and to those who see many patients from Latin America and the Caribbean, including Haiti. The book does not use common psychiatric language to describe human suffering. Instead, Farmer and his collaborating authors are descriptive and often literary in the language in which they relate events that happened and to whom. For instance, Farmer includes the following quote from an article in the Boston Globe: “With thousands of bodies and minds shattered—and the emergence of a lethal cholera epidemic—the Partners In Health workforce in this country constituted almost exclusively of Haitians soared….Partners In Health hired mental health specialists, recruited amputees to visit the limbless, and sheltered forsaken children” (p. 238). Bereavement on a very large scale, depression, posttraumatic stress disorder, and other psychiatric syndromes are readily evident from the prose used to describe the suffering of survivors.

Hospitalized people with common syndromes for which we consult are described in detail: children whose crush injuries require amputations, patients in extreme pain and in great need of analgesia, and parents separated from their children as a result of their own injuries and need to obtain lifesaving medical care. The anguish and deaths of so many people with so few medical supplies and few doctors to care for them are nearly impossible to bear, for the authors and perhaps the readers. Nevertheless, it is a tremendous service that Farmer has provided in writing this book and, as he makes clear, a very difficult one. When one works in an acute disaster setting, doing the work is all that one can bear, much less having to revisit the disaster and write about it. Farmer recognizes the importance of this type of work, and his team aided him in completing this effort. In part, the book also represents “caring for the caretakers,” an essential part of self-care in the disaster context (5). It provides a firsthand medical look at working within an acute disaster context, in a country well known to Farmer for many years, as well as social/medical system diagnoses, prognoses, and treatment recommendations on a policy level.

Farmer's social/medical diagnoses are grim, yet they leave room for hope. He and his colleagues make the point many times that Haiti, which became an independent country in 1803 after a slave revolt, has been punished ever since by Western nations (especially France and the United States), even having to pay reparations to France until 1950 for having deprived it of a colony. Farmer traces Haiti's lack of a stable government and lack of solid medical and social services to this heritage. Because of political instability, largely secondary to this history, the prognosis is not rosy. Treatment progress will only be achieved with efforts sustained over many years by those individuals and entities, especially governments and private donors, who will work to strengthen the political, governmental, and social fabric of the whole country. There is a good start with the rebuilding and restoration of hospitals and a medical school, perhaps even a “building back better,” as Farmer and President Clinton would have it. Even as the author focuses on primary care and specialty surgical care, it requires no imagination to know that the care for those who suffer from mental illness, which is likely as bad or worse, needs to be addressed as well, and such care will similarly benefit if infrastructural governmental strengthening can occur and continue.

de Jong  J:  (Disaster) Public mental health, in  Post-traumatic Stress Disorder . Edited by Stein  DJ;  Friedman  MJ;  Blanco  C.  Oxford, United Kingdom,  Wiley Blackwell, 2011, pp 217–262
 
Ravenscroft  K:  Haiti earthquake psychiatric relief.  Am J Psychiatry 2010; 167:1038
[PubMed]
[CrossRef]
 
Ursano  RJ;  Fullerton  CS;  Weisaeth  L;  Raphael  B:  Textbook of Disaster Psychiatry .  Cambridge, United Kingdom,  Cambridge University Press, 2006
 
Stoddard  FJ;  Pandya  A;  Katz  CL (eds):  Hidden Impact: What You Need to Know for the Next Disaster: A Practical Mental Health Guide for Clinicians .  Sudbury, Mass,  Jones & Bartlett, 2010
 
Merlino  JP:  Rescuing ourselves: self-care in the disaster response community, in  Disaster Psychiatry: Readiness, Evaluation, and Treatment . Edited by Stoddard  FJ;  Pandya  A;  Katz  CL.  Washington, DC,  American Psychiatric Publishing, 2011, pp 35–48
 
References Container
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References

de Jong  J:  (Disaster) Public mental health, in  Post-traumatic Stress Disorder . Edited by Stein  DJ;  Friedman  MJ;  Blanco  C.  Oxford, United Kingdom,  Wiley Blackwell, 2011, pp 217–262
 
Ravenscroft  K:  Haiti earthquake psychiatric relief.  Am J Psychiatry 2010; 167:1038
[PubMed]
[CrossRef]
 
Ursano  RJ;  Fullerton  CS;  Weisaeth  L;  Raphael  B:  Textbook of Disaster Psychiatry .  Cambridge, United Kingdom,  Cambridge University Press, 2006
 
Stoddard  FJ;  Pandya  A;  Katz  CL (eds):  Hidden Impact: What You Need to Know for the Next Disaster: A Practical Mental Health Guide for Clinicians .  Sudbury, Mass,  Jones & Bartlett, 2010
 
Merlino  JP:  Rescuing ourselves: self-care in the disaster response community, in  Disaster Psychiatry: Readiness, Evaluation, and Treatment . Edited by Stoddard  FJ;  Pandya  A;  Katz  CL.  Washington, DC,  American Psychiatric Publishing, 2011, pp 35–48
 
References Container
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