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Disaster Psychiatry in Haiti: Training Haitian Medical Professionals

Westermeyer, Joseph John MD, MPH, PhD

Journal of Nervous & Mental Disease: November 2012 - Volume 200 - Issue 11 - p 1005–1006
doi: 10.1097/NMD.0b013e3182718afd
Book Reviews

Staff Psychiatrist Minneapolis Veterans Administration Medical Center MN and Professor of Psychiatry and Adjunct Professor of Anthropology University of Minnesota Minneapolis

This remarkable book by an uncommon author took root in the devastating 2010 earthquake in Haiti. Dr Kent Ravenscroft—a volunteer psychiatrist providing services there—had visited Haiti 50 years earlier as an anthropology student, conducting an ethnographic study of voodoo healing. By chance, his field study area became the epicenter for the recent earthquake. In addition to understanding the Haitian world view, he spoke sufficient Creole for sociable conversations. His linguistic skills and past experiences aided his understanding of his patients’ complaints and their responses to his queries. In sum, he undertook his mission with credentials par excellence for quickly getting to the essence of clinical problems in that exceptional context.

The author’s expressed goal in writing this book was to provide an experiential perspective of “disaster psychiatry”—a topic whose cognitive components have been well addressed (Stoddard et al., 2011; Ursano et al., 2007). He used an ideal method for achieving this end: daily journaling. This approach has provided readers with a grand array of fact and affect. Dr Ravenscroft takes us along on a journey bounded by destruction and loss, driven by need and exigency, and hampered by logistic challenges, all in a lovely island setting with a unique history.

His brisk case vignettes furnish instructive examples, from cases precipitated by loss and stress to those wrought by physical injury, infectious disease, endocrine responses, seizures, and dehydration. Some psychiatric disorders began anew with the earthquake; others had worsened in long-disabled-but-stable people bereft of their medications or support systems by the earthquake. Because many of Ravenscroft’s patients are children or adolescents, his training as a child psychiatrist imparts an element lacking from many resources on disaster psychiatry. Experience in consultation psychiatry also served him well in this venue: he sought out strengths in his patients’ characters and in their social networks, and his clinical acumen serves us well in demonstrating how dynamic clinical understanding trumps prescription writing as a key requirement for disaster psychiatry.

He displayed theatrical prowess in recruiting neighbors as healing agents, transforming their anxious teasing to empathetic understanding. Prescribing medications deftly and briefly in most cases, he put the pharmacology button on fast-forward and chased down brain imaging equipment when called for. Often, he played the teacher-coach, instructing patients on how to control and abate their symptoms and how they might help others with similar problems. In numerous cases, especially the life-threatening or the uncertain ones, he arranged instructive follow-up visits for us on a later day in his journal. Although modest in his presentation, Dr Ravenscroft and this context were meant for another: his ministrations are enlightened, effective, and humane. I think you will find some of them brilliant, as I did. Perhaps, most importantly to Haiti, he was able to model his interventions to his Haitian colleagues and trainees, who trusted him even when they initially expressed doubts about his explanatory models and therapeutic tactics.

His daily journal serves up more than cursory glances at his colleagues, helpers, and administrators—both Haitian and non-Haitian. Such work, conducted at the interface of life with death, inevitably summoned disagreement and, sometimes, conflict. Ravenscroft emphasized dialogue and mutual team support as an antidote, nevertheless demonstrating how intricate, even thorny, a matter this can be. In his cameos of collegial support, Ravenscroft ranges from sensitive to blunt but in ways designed to maximize understanding, facilitate change, and minimize blame—except in those few instances when he censures himself for his remarks or decisions. Even then, he does not belabor the matter: he takes his thumps and moves on. In this regard, he sets a high threshold for his learner-readers, accentuating charitable, forgiving projections over petty faultfinding. However, he is not Pollyannaish in his interactions with the staff, Haitian or non-Haitian. On a few occasions, he conducts private conversations (of course, now made public to the entire readership of the book!) aimed at helping the staff through understanding how their foibles might undermine their efforts. Examples included, among others, failure to take “time out,” thus, risking burnout in one case, and, in another, a habit toward wearing an overrevealing dress, which derailed some patients from the task at hand. Ravenscroft did not find these confrontations easy, obsessing over them until practical exigencies pushed him to interventions. In these cases, he demonstrated his appreciation for the obligations that senior clinicians owe to younger colleagues, even and perhaps particularly in the midst of disaster. In this and other regards, the book conjured up scenarios of a “psychiatric MASH unit”—from the Korean War era movie, “MASH.”

You may have gathered from the first paragraph that Ravenscroft was not a young man when he began his month-long trek into a staggering disaster as well as into reveries of his own past. Such was the case; he was 70 years old. However, he was fit before he went, and he kept to his daily exercise while he worked in Haiti. Although not all seniors would be up to the task, hopefully, more of us will adopt him as a role model. His story tells us how an experienced elder can support junior colleagues tested to the limit by appalling circumstances. (In my 20s, I was fortunate to have had a 70-something physician, the former director general of public health in an Asian country at war, as a Ravenscroft-like counselor and confidant. What a boon!)

The nature of Ravenscroft’s journal made it more than he perhaps intended it to be. First, it is a good read! After I first picked it up, I crammed every spare minute into finishing it. He knows how to capture and keep a reader’s attention. Second, his journal puts a human face to the historical record regarding the Haitian earthquake but likewise to all major disasters several weeks into the process of personal and societal recovery. Students of disasters should find it informative in preparing future operations. Third, the personal stories he related about himself exposed more than what many readers might have asked him to relate. However, these autobiographical details explained to the reader his understanding of the tasks before him, their special impediments for him, and what it took for him to meet those tasks. He did not hide his feet of clay, thereby reminding us gently that any of us can travel leagues and—at least for a time—perform heroic deeds of legendary proportions.

Who ought to peruse Dr Ravenscroft’s journal? Psychiatrists going into disaster areas, of course, but psychiatrists working in emergency rooms, medical and surgical units, prisons, and veterans’ hospitals and clinics and the military would also benefit. It would prepare other physicians soon to inundate themselves in similar cauldrons of suffering while moreover exposing themselves to serious risk. Medical educators could profit from a read, asking themselves how they would prepare their charges for work in similar circumstances. Medical students could manage a quick summer’s read (only 178 pages, with pictures!) and gain appreciation for future service opportunities. Health administrators might come to understand us better, not only as humans, surely, but also as sometimes-difficult minions who cannot avoid mediating between “the authorities” and suffering people.

Joseph John Westermeyer, MD,

MPH, PhD

Staff Psychiatrist

Minneapolis Veterans Administration

Medical Center MN

and Professor of Psychiatry

and Adjunct Professor of Anthropology

University of Minnesota

Minneapolis

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DISCLOSURE

The author declares no conflict of interest.

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REFERENCES

Stoddard FJ, Pandya A, Katz CL (2011) Disaster psychiatry: Readiness, evaluation, and treatment. Washington, DC: American Psychiatric Press, Inc.
Ursano RJ, Fullerton CS, Weisaeth L, Raphael BEds (2007) Textbook of disaster psychiatry. Cambridge, UK: Cambridge University Press.
© 2012 Lippincott Williams & Wilkins, Inc.