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Haitians culture health refugees immigrants

Background on Country of Origin

The Republic of Haiti is lies on the western third of the Island of Hispaniola in the West Indies. The Eastern portion of Hispaniola is the Dominican Republic. Haiti is mountainous, densely populated (>7,000,000 people), and has the lowest per capita income in the Western Hemisphere. Most of the population is black descendents of African slaves brought to the West Indies by French colonists (Pan American Health Organization [PAHO], 1999).

Poverty in Haiti is a result of a matrix of overpopulation, high unemployment rate (60%), high and accelerating inflation rate, high illiteracy rate (55%), destruction of natural resources, no industry or exports, and little viable industrial or government infrastructure. Results of this poverty include extraordinarily high infant mortality rates (74/1000 live births), high child death rates (133/1000 < 5 years), short adult life spans (approximately 50 years), and high rates of acute and chronic illnesses (PAHO, 1999). In Haiti, "the equivalent number of years in full health that a newborn child can expect to live" is 42.9 years for men and 47.3 years for women. The health status of Haitians is thus in the bottom 20% of nations worldwide (World Health Organization [WHO], 2001). The full life expectancy for Haitians is 52.1 years for men and 57.3 years for women (PAHO, 1999).

From 1957-1971, "President for Life" Francois "Papa Doc" Duvalier ruled Haiti. Duvalier's secret police, the tontons macoutes used terror and repression to control the country. "Papa Doc" Duvalier was succeeded by his son, Jean-Claude "Baby Doc" Duvalier in 1971. In 1990, Jean-Bertrand Aristide was elected president and there was tremendous optimism in Haiti that the Duvalier's reign of terror was finished. In 1991, Aristide was overthrown by elements of the former regime, but with assistance from the U.S. was returned to power in 1994. The Aristide administration (later the Preval administration; and then again Aristide) was more democratic and less corrupt than previous administrations, but the country remains impoverished and the military remains powerful.

History of Immigration

Haitians come to the U.S. and to a lesser degree, France and other Western European countries, as legal immigrants, illegal immigrants, and as refugees. Legal immigration tends to be difficult for Haitians, but because of desperate economic conditions in Haiti, the rate of illegal immigration remains high. Most illegal immigrants to the U.S. leave Haiti via small boat, despite significant risk of drowning or interdiction in the sea journey. The number of refugees, never very great, has declined since the early 1990s to several thousand/year. Most new Haitian immigrants and refugees are adults or teens (with few infants or old people), and most are poorly educated.

Culture

Many Haitian refugees and immigrants come from the city of Port-au-Prince, but may actually be from rural backgrounds. Most are poorly educated, speak only Creole, and have marginal or no ability to read or write. Influences on Haitian culture include their West African origins, experiences as slaves, and the crushing poverty of Haiti. The better-educated Haitians tend to be more future-oriented, while those with less education tend to be oriented to the present, and, like many refugees, also oriented to a past that may become increasingly romanticized as time passes in the new land. As is true among most people, socioeconomic status is a huge factor in how Haitians categorize themselves. In both Haiti and the U.S., the vast majority of Haitians are poor and undereducated. There is a small middle class and a miniscule wealthy class. It should be noted that despite physical similarities, there is often little interaction or perceived commonality between native-born American Blacks and Haitians.

Communication

Most Haitians speak Creole, a French/pidgin dialect that is seldom written; and the educated also speak French. Communication tends to be relatively direct (except, perhaps, regarding certain religious and personal matters). Some Haitians will indicate agreement with a person of higher socioeconomic status rather than risk conflict in disagreement. In communicating with friends, direct eye contact, expressive or animated tone of voice, and expressive hand gestures are common, as is touching the other person. Personal space is often not as pronounced as among some other cultures, and interaction may be very close. Touch by caregivers is often appreciated (Colin & Paperwalla, 1996).
Interpreters outside the family may be mistrusted, but use of children to interpret (the most likely English speakers) carries the potential of creating conflict within the family or within the interpreter who may be called on to deal with difficult matters. An interpreter unknown to the patient may be better than a friend. Written materials are often of little use.

Religion

Most Haitians (80%) are Catholic, and many of these also believe to at least some extent in Voodoo (also spelled Voudou, Vodoun, or Vodun) (Brown, 1998). There are increasing numbers of Haitians who have become Protestant, e.g., Baptist, because of missionary contact in Haiti or in "Little Haiti" areas in the U.S. In either case, religion may play a central role in the life of an individual, especially during illness or other crisis. From a cosmopolitan perspective, religion may be seen as akin to magic.
Voodoo beliefs include the presence of a powerful spirit world from which neglected ancestors, malicious spirits, or even the raised or living dead (zombies) may come to the living to bring misfortune or death. Zombification, or more accurately, catalepsy is a result of poisoning with neurotoxins (tetrodotoxins and possibly others) from one or more species of puffer fish or amphibians (Craan, 1988). Spirits are known as loas, mysteres, or saints. Some Haitians work to maintain a strong relationship with this spirit world and significant effort made to ensure that the relationship is protective or at least not damaging. Spirits may be controlled or brought into activity through ritual and/or the efforts of sorcerers or practitioners. Types of Voodoo or related practitioners (Coriel, 1983; Cosgray, 1995) include:

Male priests are known as hungan and female priests as mambo. Practitioners of black magic are called bokors. Catholic saints are incorporated into Voodoo, except that they may have different functions and names in Voodoo. What appear to be Catholic amulets may actually be Voodoo or in some cases (from a Voodoo perspective), both Catholic and Voodoo.

Social Relations

The extended family is the ideal social unit, but because of previously noted difficulties in immigration, is relatively rare in the U. S. In many respects, Haitian society is matriarchal, especially where child-rearing and family life is concerned. Common-law marriage is the norm (Coreil, Barnes-Josiah, & Cayemittes, 1996). The man however is likely to hold ultimate control and authority in most matters, especially those related to the world outside the family. Parents are authoritarian and the use of force as a means of discipline is common. Like so many other refugee and immigrant groups, many Haitians are deeply concerned about the negative effects of American culture on child-rearing and family life. Respect for adults, support to the family, and achieving in school are strongly held values that often do not survive in American urban settings (Colin & Paperwalla, 1996).

As noted in the section on communication, relationships and communication may
be very affectionate and even unrestrained. Many Haitians live in ethnic enclaves that serve as cultural/emotional support systems to people who have lost their primary support systems.

Health Beliefs and Practices

Educated Haitians or those with experience in modern health care are likely to have a greater understanding from a lay perspective of the scientific basis of illness. Illness may also be attributed to natural causes outside the body, such as cold, heat, winds, or humoral imbalance (Colin & Paperwalla, 1996). Changes in eating, living, or other habits may also influence health and illness. Illness may be seen as punishment (malediction) from God, especially when a person's relationship with God is weakened and thus one's body also is weakened. A state of depression means generalized weakness, dejection, and worry that make one vulnerable to illness (Martin, et al, 1995). As noted earlier, some sickness is thought by some Haitians to be a result of expedition or illness sent by another through spirits. Specific culture-bound illnesses of Haiti (Colin & Paperwalla, 1996; Coreil, 1983; Coreil, Barnes-Josiah, & Cayemittes, 1996) include:

Haitian beliefs about health and illness may also be strongly influenced by life in Haiti where there is limited access to the most basic health care (clean water, immunizations, prenatal/ obstetric care, antibiotics, and so on). Thus, a reliance on folk and/or spiritual explanations and treatments for illness may simply be the only option a person has ever had. Health care providers should also be open to (and respectful of) the likelihood of patients simultaneously using multiple sources of care for an illness: herbalist or docte fey, primary care clinic, and sorcerer.

In seeking health care, the primary focus among most Haitians is on solving a specific problem. In many cases, a Haitian who presents at a primary care or other source of cosmopolitan health care will already have tried home or traditional remedies. Use of modern health resources for prevention of illness and health promotion is uncommon. However, use of traditional or magic-religious measures to prevent illness or harm is almost universal among Haitians (DeSantis & Thomas, 1990). Traditional means of health promotion and disease prevention (Colin & Paperwalla, 1996) include:

The rate of chronic illnesses such as diabetes and hypertension is extraordinarily high among Haitians and treatment is very difficult because of high rates of noncompliance (Preston, et al, 1996). Noncompliance may be due to difficulty understanding the nature of chronic illnesses, difficulty accessing and maintaining a relationship with health care providers, and reliance on traditional or magical means of treatment. Socioeconomic status plays a well known role in increased morbidity and mortality in all populations and in all diseases - and such is the case with Haitians. Self-medication, including with black market antibiotics or antibiotics loaned by friends is common.

Breast feeding is the norm for Haitians, but bottle feeding allows the mother to work outside the home, hence the bottle may be an economic necessity in developed locales. It is common for Haitian mothers to mix starchy additives to formula to promote weight gain and docility in the infant. Women make regular use of purgatives during pregnancy. Newborns are also given purgatives and their use may be continued through childhood (Thomas & DeSantis, 1995).

Privacy is important to Haitians, and especially around people outside the culture, modesty is important. Thus, some parts of the physical examination may result in discomfort, especially if the practitioner does not endeavor to keep the patient's body covered. Breast self exams are difficult to teach because of the modesty factor. Modesty and privacy also play a role in health histories often being incomplete (Colin & Paperwalla, 1996).

Health Problems and Health Screening

More than 50% of all Haitian preschoolers are malnourished; and more than 35% of all Haitian women are anemic and many have experienced complications of pregnancy and/or delivery (PAHO, 1999). Tropical infectious diseases are common, as are obesity and related chronic health problems such as hypertension and diabetes (Molokhia & Oakeshott, 2000; PAHO, 1999). Common health risks or problems of new Haitian immigrants (Ackerman, 1997; Beach, Steit, Addiss, Prospere, Roberts, & Lammie, 1999; Halstead, Streit, LaFontant, Putvatana, Russell, Sun, Kanesa-Thasan, Hayes, & Watts, 2001; Holcomb, et al, 1996; Molokhia & Oakeshott, 2000; PAHO, 1999) include:

For screening guidelines, see e Infectious Diseases web site and Refugee Health Problems, as well as referring to the above.

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Author: Charles Kemp, FNP, FAAN

Links (also see links in references)

Electric Gallery: http://www.egallery.com/haiti.html - Haitian art, including Voodoo flags. Definitely interesting.

References

Ackerman, L. J. (1997). Health problems of refugees. Journal of the American Board for Family Practice. 10:337-48.

Beach, M.J., Steit, T.G., Addiss, D.G., Prospere, R., Roberts, J.M., & Lammie, P.J. (1999). Assessment of combined ivermectin and albendazole for treatment of intestinal helminth and Wucheria bancrofti infections in Haitian schoolchildren. American Journal of Tropical Medicine and Hygiene. 60(3), 479-486.

Brown, P.L. (1998). Where the spirits of voodoo feel at home. New York Times. 12/31/98, B1, B18.

Colin, J. M. & Paperwalla, G. (1996). Haitians. In J. G. Lipson, S. L. Dibble, & P. A. Minarik (Eds.), Culture & nursing care: A pocket guide. (pp. 139-154). San Francisco: UCSF Nursing Press.

Coreil, J., Barnes-Josiah, D.L., & Cayemittes, A.A.M. (1996). Arrested pregnancy syndrome in Haiti: Findings from a national survey. Medical Anthropology Quarterly. 10(3), 424-436.

Coriel, J. (1983). Parallel structures in professional and folk health care: A model applied to rural Haiti. Culture, Medicine and Psychiatry. 7(2), 131-151.

Cosgray, R. E. (1995). Haitian Americans. In J. N. Giger & R. E. Davidhizar (Eds.), Transcultural nursing: Assessment and intervention (pp. 501-523). St. Louis: Mosby.

Craan, A.G. (1988). Toxicologic aspects of Voodoo in Haiti. Biomedical and Environmental Sciences. 1(4), 372-381.

DeSantis, L. & Ugarriza, D. N. (1995). Potential for intergenerational conflict in Cuban and Haitian immigrant families. Archives of Psychiatric Nursing. 9(6), 354-364.

DeSantis, L. & Thomas, J. T. (1990). The immigrant Haitian mother: Transcultural nursing perspective on preventive health care for children. Journal of Transcultural Nursing. 2(1), 2-15.

Halstead, S.B., Streit, T.G., LaFontant, J.G., Putvatana, R., Russell, K., Sun, W., Kanesa-Thasan, N., Hayes, C.G., & Watts, D.M. (2001). Haiti: Absence of dengue hemorrhagic fever despite hyperendemic dengue virus transmission. American Journal of Tropical Medicine and Hygiene. 65(3), 180-183.

Holcomb, L. O., Parsons, L. C., Giger, J. N. & Davidhizar, R. (1996). Haitian Americans: Implications for nursing care. Journal of Community Health Nursing. 13(4), 249-260.

Martin, M. A., Rissmiller, P., & Beal, J. A. (1995). Health-illness beliefs and practices of Haitians with HIV disease living in Boston. JANAC. 6(6), 45-53.

Molokhia, M. & Oakeshott, P. (2000). A pilot study of cardiovascular risk assessment in Afro-Caribbean patients attending an inner city general practice. Family Practice. 17(1), 60-62.

Pan American Health Organization. (1999). Haiti: Country health profile. Accessed 12/8/2002 http://www.paho.org/English/SHA/prflHAI.htm

Pape, J. & Johnson, W. D. (1993). AIDS in Haiti. Clinical Infectious Diseases. 17 (Supplement 2), S 341-354.

Preston, R. A., Materson, B. J., Yoham, M. A., & Anapol, H. (1996). Hypertension in Haitians: Results of a pilot survey of a public teaching hospital multispecialty clinic. Journal of Human Hypertension. 10(11), 743-745.

Thomas, J. T. & DeSantis, L. (1995). Feeding and weaning practices of Cuban and Haitian immigrant mothers. Journal of Transcultural Nursing. 6(2), 34-42.

World Health Organization (2001). Healthy life expectancy rankings. Accessed 12/1/2002 http://www3.who.int/whosis/hale/hale.cfm?path=whosis,burden_statistics,hale&language=english

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