In 2004, the final death toll in Haiti from Tropical Storm Jeanne was recorded at 3,006; of these, 2,826 in Gonaïves, a city floating in ruins. The road to Gonaïves was washed out, leaving the city and the department of Artibonite cut off for days from the rest of the country. Dr Juan Carlos Chávez, who headed the Cuban medical team in Haiti at the time, recalls that 17 Cuban health professionals were working in the area when the storm barrelled through, among the 400 already serving in the country. They were later joined by another 72 doctors, nurses, technicians and engineers sent directly from Cuba.
“The hospital was so damaged, it had to be shut down,” recalls Dr Chávez, now Dean of the Sancti Spíritus Medical School in central Cuba. Many houses were destroyed, including some of the homes of the Cuban team members; corpses of people and animals floated visibly in the dirty flood waters covering the city, or solidifying in the drying mud. An epidemiological assessment confirmed the imminent threat of epidemics.
The flooding and mudslides from the September 2004 storm had disrupted the lives of some 300,000 people; at least half of these among one of disaster’s most vulnerable populations -children.[1,2] Their trauma is illustrated by what Dr Chávez describes as his own most vivid memory of the storm’s aftermath: “He was only eleven years old, I later learned. He arrived with his three-year-old brother in tow. And slowly his story came out: his parents had tied the younger boy to a piece of wood to save him from the floodwaters. The older child managed to get them both to safety and care for his brother until help came. But he had witnessed his parents carried away. The strength of that child left a mark on us all.”
As the storm passed, Cuban doctors in Gonaïves began spotting children like him on the muddied streets, wandering alone and disoriented. And little by little, says Dr Chávez, more of these “children of the missing” began trickling in to medical posts set up by the Cubans when the hospital was destroyed. Soon, there were over 150, prompting UNICEF and local Haitian authorities to join Cuban health professionals in setting up a special shelter for the children. In the end, the shelter was a temporary home for 166 children, aged 3-17 years. UNICEF provided meals, shoes, clothing and blankets; while the Cuban medical team assumed the challenge of providing care and day-to-day activities, including games, sports, and music, in an attempt to create a sense of safety and support for these youngsters.
Their dire situation -already among the hemisphere’s poorest children, many of them now orphaned- made their mental health status as worrisome as their physical condition. Yet, experience suggested that child survivors often find it difficult or impossible to express their trauma verbally, in turn making it difficult for health care professionals to understand the child’s perspective and properly address his or her mental health needs.
At the shelter, the Cuban team adopted an element of “psychological first aid” -pragmatic interventions with disaster survivors aimed at reducing stress reactions and helping them address their immediate needs in a post-disaster situation -by encouraging the children to express their feelings through art.[3,4]
Analysis of these drawings assisted the professionals on the ground to better understand and work with these very special disaster victims. “Analyzing the children’s artwork facilitated communication between the Cuban team and these children [and helped] to better assess the children’s ability to cope with the disaster,” explained clinical psychologist Fernanda Zulueta, who evaluated the drawings. In addition, it has been shown that drawing may help children gain symbolic control over events that are confusing and frightening.[5]
Drawing from a 13-year-old in the shelter: black only, with a cloud overwhelming a very small house and a single flower.
“There are many aspects to analyze in a child’s drawing,” says Zulueta, “and you also have to consider the context and their developmental stage.” Looking at the drawings by children in the shelter, she analyzed the type of objects drawn, their size, and how they were distributed throughout the page, as well as the presence or absence of human figures. The colors used offered clues to the emotional state of each child. It has been well established, for example, that children with healthy psychological development in normal conditions use many different colors and intense shades, preferring warm colors during the early years of life. The use of darker shades, cooler colors and neutral colors such as blue and grey by young children often indicate sadness, affective difficulties and even depression.[5]
The Color of Calamity
Zulueta classified the children in three age groups: pre-schoolers (aged 3-5 years); school-age children (aged 6-11 years); and adolescents (aged 12-16 years). Her findings and analysis:
– The drawings of the youngest children were developmentally -appropriate, that is, they were able to color within the space of the page. Many of these children drew houses without people, reflecting the loss of their homes and families. Ninety-two percent of the 56 children in this age group chose the color black and the remaining 8% chose brown; other colors were noticeably absent. The lack of brighter colors reflected reactions of sadness and bereavement.
– The drawings of the 76 school-age children were also developmentally appropriate, showing more clarity and neatness in design. But like the younger children, they drew empty houses devoid of living forms. Their shapes were rigid, characterized by vertical and horizontal lines and less curves. In this group, 45% of children used black, 43% brown, and only 12% yellow.
– Among the adolescents, many of the same characteristics were present, although the size of the objects they drew were generally out of proportion to the overall composition of the drawing, indicating the magnitude of the events they had recently experienced. In this group, 55% used the color black, 33% used brown, 7% used yellow and 5% used blue.
In her daily practice in central Cuba, Zulueta works mainly with children. “I am still struck by those drawings from the children of Gonaïves,” she told MEDICC Review. “I don’t believe I have ever interpreted such sadness, such loss, in such a large number of children. But at least we have this,” she continued, “that they were able to express what they felt and we were better able to feel with them, thus starting the much longer healing process.”
About a month after the storm, the immediate relief efforts ended. Although many of the acute health problems caused by the disaster had been addressed, other pre-existing and serious public health issues -such as lack of access to clean drinking water- had been exacerbated. In this context, the Cuban team began shifting its mission from emergency services back to preventive, primary care. A new hospital was opened in the Gonaïves neighborhood of Rabateau to replace the hospital de stroyed by the storm, its staff including some of the 499 Cuban health professionals currently working in Haiti.
References
- Center for International Disaster Information [Homepage in the Internet] Caribbean: Storms – USAID-04: 13-Oct-04.[Cited 2008 April 10] Available from: http://cidi.org/disaster/04b/ixl127.html)
- UNICEF [homepage on the Internet] At a glance Haiti: One year after Hurricane Jeanne, recovery continues. 2005 Sept 18.[Cited 2008 April 10] Available from: http://www.unicef.org/infobycountry/haiti_28308.html.
- Halper J and Tramontin M. Psychological First Aid. In: Disaster Mental Health: Theory and Practice. Canada: Thomson: Brooks/Cole;2007. p.199-223.
- Garrett A, Grant R, Madrid P, Brito A, Abrasmson D, Redlener I. Children and megadisasters: Lessons learned in the new millennium. Adv Pediatr. 2007;54:189-214.
- Looman WS (2006) A Developmental Approach to Understanding Drawings and Narratives from Children Displaced by Hurricane Katrina. J Pediatr Health Care. 2006;20(2):158 -166. Drawing from a 13-year-old in the shelter: black only, with a cloud overwhelming a very small house and a single flower.
