By DEBORAH SONTAG, New York Times

http://www.nytimes.com/2010/03/20/world/americas/20haiti.html

PORT-AU-PRINCE, Haiti — Inside this city’s earthquake-cracked psy­chi­atric hos­pi­tal, a schiz­o­phrenic man lay naked on a con­crete floor, caked in dust. Other patients, pad­locked in tiny con­crete cells, clutched the bars and howled for atten­tion. Feces clot­ted the gut­ter out­side a ward where urine pooled under metal cots with­out mattresses.

Walk­ing through the dilap­i­dated pub­lic hos­pi­tal, Dr. Franklin Normil, the act­ing direc­tor, who has worked there for five months with­out pay, shook his head in despair.

“I want you to bear wit­ness,” he told a reporter. “Clearly, men­tal health has never been a pri­or­ity in this coun­try. We have the desire and the abil­ity, but they do not give us the means to be pro­fes­sional and humane.”

As dis­as­ters often do in poor coun­tries, Haiti’s earth­quake has exposed the extreme inad­e­qua­cies of its men­tal health ser­vices just at the moment when they are most needed. Appalled by the Mars and Kline Psy­chi­atric Cen­ter, the country’s only hos­pi­tal for acute men­tal ill­ness, for­eign psy­chi­a­trists here have vowed to help the Hait­ian gov­ern­ment cre­ate a men­tal health care sys­tem that is more than just an under­fi­nanced insti­tu­tion in the cap­i­tal city.

“Con­di­tions at Mars and Kline are par­tic­u­larly bad, although this kind of place is not unique to Haiti,” said Dr. Giuseppe Ravi­ola, direc­tor of men­tal health and psy­choso­cial ser­vices for the Boston-based Part­ners in Health, which runs 10 hos­pi­tals in Haiti. “Still, now that we’ve seen the hos­pi­tal in the cap­i­tal city, it is clear that that we have to treat peo­ple in their communities.”

Ulti­mately, inter­na­tional experts are encour­ag­ing the Hait­ian Health Min­istry, which they say is recep­tive and eager for help, to incor­po­rate men­tal health care into the pri­mary health care sys­tem and to make it avail­able through­out the country.

Right now, though, the need for psy­cho­log­i­cal first aid and emer­gency psy­chi­atric treat­ment is so acute that for­eign psy­chi­a­trists are see­ing patients, set­ting up pro­grams and rapidly train­ing Hait­ian doc­tors, nurses and com­mu­nity work­ers in every­thing from psy­chophar­ma­col­ogy to group relax­ation tech­niques. (Before the quake, there were only about 15 psy­chi­a­trists in all of Haiti.)

The for­eign psy­chi­a­trists empha­size that they have found Haitians to be impres­sively resilient, but the dis­as­ter has nonethe­less set off reac­tions rang­ing from anx­i­ety through psy­chosis. Most wor­ri­some are cases like that of Guerda Joseph, a 41-year-old woman who tum­bled into a cata­tonic depres­sion shortly after she was pulled from the rub­ble of her home. Mute and nearly immo­bi­lized ever since, she lies on flo­ral sheets at the Gen­eral Hos­pi­tal, her Bible tucked beside her pil­low, her 25-year-old adopted son by her side day and night.

More com­mon, though, is what Dr. Lynne Jones, a child psy­chi­a­trist and dis­as­ter expert with the Inter­na­tional Med­ical Corps, calls “earth­quake shock,” a per­sis­tent sen­sa­tion that the earth is still shak­ing, which makes the heart race and causes chest pain.

“This is an under­stand­able response, and it’s impor­tant to let peo­ple know, ‘You are not crazy,’ ” Dr. Jones said. “I use a kind of metaphor: ‘Your body has a very effec­tive fire alarm. One of the rea­sons you’re alive today is that it went off dur­ing the earth­quake. You ran out of that build­ing. Great, you sur­vived. Unfor­tu­nately, the fire alarm is now sen­si­tive and goes off when you don’t want it to, or maybe it never shut off.’ ”

For those with a his­tory of men­tal ill­ness, the earth­quake has been espe­cially desta­bi­liz­ing. Many lost homes, care­tak­ers and med­ica­tion sup­plies, and the insti­tu­tion­al­ized were dis­placed, too.

Mars and Kline, partly dam­aged, evac­u­ated most of its 100 acutely ill patients; only some have returned. And the sole hos­pi­tal for chronic men­tal dis­eases, Défilé de Beudet in Croix-des-Bouquets, seri­ously dam­aged, shifted scores of patients to the grass outside.

Inside Mars and Kline’s walls, neigh­bors have estab­lished a tent city, fes­toon­ing the 52-year-old psy­chi­atric hospital’s facade with laun­dry. Their pres­ence has cre­ated a secu­rity night­mare for the institution’s guards, said Louis­ner Aubin, the admin­is­tra­tor, given that patients have returned from the earth­quake espe­cially agi­tated and some­times violent.

“We have to lock up the worst cases to keep the worst from hap­pen­ing,” Mr. Aubin said.

Also in the court­yard are two psy­chi­atric triage tents where more than 100 peo­ple are show­ing up daily, report­ing extreme stress and post-traumatic symp­toms of night­mares, mem­ory lapses, sleep dis­tur­bances and loss of appetite, Dr. Normil said. Some, with psy­choses, have been admit­ted, and more will arrive need­ing admit­tance, he said.

“We’re in a cri­sis sit­u­a­tion,” he said. “Even before the earth­quake, we did not get the resources to feed or clothe our patients prop­erly. We had barely any staff, and these are patients who could be reha­bil­i­tated if we had the means.”

Leav­ing Mars and Kline to walk to the nearby Gen­eral Hos­pi­tal, Nicholas Rose, a psy­chi­a­trist from Eng­land, said, “It’s straight out of Hog­a­rth, really,” refer­ring to the 18th cen­tury engrav­ings of an insane asy­lum by the artist William Hog­a­rth.

In and around the two hos­pi­tals, appar­ently men­tally ill men wan­der the streets, ragged and filthy. One sits naked atop a pile of rub­ble, another wears caked mud.

At the Gen­eral Hos­pi­tal, for­eign psy­chi­a­trists say that they are see­ing sev­eral new cases daily of psy­chosis, severe depres­sion and other dis­or­ders. Guer­line Pré­sumé, a for­merly mild-mannered young mother, was admit­ted a few weeks ago for what was diag­nosed as a manic dis­or­der. On the day of the earth­quake, she ran from a col­laps­ing house that killed her older sis­ter and dis­ap­peared, scream­ing, into the streets. It took her hus­band a month to find her; when he did she was mut­ter­ing and spit­ting obscenities.

“The earth­quake drove her crazy; it’s that sim­ple,” her hus­band, Wilkin­son Charles, said, adding that he feared she had been “taken advan­tage of” while liv­ing with­out him on the streets.

Many with less severe issues are seek­ing help at the med­ical clin­ics in the big tent cities, like the one in Pétionville, where Dr. Jones and a psy­chi­atric col­league, Peter Hughes, ran a men­tal health clinic one day last week while simul­ta­ne­ously train­ing a Hait­ian internist.

“Remem­ber, these are not our patients, these are your patients,” Dr. Jones said to Dr. Charles Samuel, the internist. “We are going to teach you so that you can carry on.”

The doc­tors saw Jean Pierre Fran­cil­lon, shy and smil­ing, who was suf­fer­ing high blood pres­sure and com­plained of trem­bling and heart pal­pi­ta­tions; Ketie Kledano, 52, who said she was anx­ious, plagued by headaches and could not sleep or eat; and Naomi Joseph, 8, who wore a pink cam­ou­flage “USMC Cutie on Duty” T-shirt and, accord­ing to her mother, “spits, spits, spits” all day long.

There were some cul­tural and lin­guis­tic bar­ri­ers. After Dr. Samuel said of Mr. Fran­cil­lon, “The truth is what he’s talk­ing about is not seri­ous. It’s a real­ity that goes along with being Hait­ian,” Dr. Hughes tried another approach. He explained the the­ory of the bod­ily fire alarm and told Mr. Fran­cil­lon, “You’re not mad,” which the Cre­ole inter­preter deliv­ered as, “You’re not angry.”

Lead­ing Mr. Fran­cil­lon to a cot, where he slipped off his mud-caked black loafers, Dr. Jones guided him through a relax­ation exer­cise. Try­ing to get him to visu­al­ize a calm­ing moment, she asked, “Have you ever sat in the ocean and had the water wash over you?”

“Not often,” he said.