Meeting the Challenge of Global Mental Health Disparities
Acknowledging the role that structural violence plays in driving GMH disparities is a first step toward reducing them (Ecks and Sax 2005; Williams and Mohammed 2013; Patel 2015). Mental health of Haitian migrants in the Dominican Republic can be traced back to conditions set in place from unfair institutional practices, such as denying them authorized documentation, which in turn pushes migrants into lower socioeconomic positions and deprives them with a sense of control over one’s life. Linked to this policy of unfair documentation is a history of anti-Haitianism, inherited from the legacy of slavery and Eurocentrism that privileged lighter skinned individuals with greater social status. Structural violence includes not only these broadly operating economic and political forces but also the everyday ways in which people conceptualize and explain health disparities. For some Dominican participants, the poor living conditions of many migrants, and their risk of waterborne diseases like cholera, were due in some degree to intrinsic character flaws found only among Haitians. In conversations with Haitian participants, however, we heard them link their suffering to lack of infrastructure and access to healthcare in their communities, as well as the hurtful interpersonal relations with Dominicans. In the end, many migrants felt powerless to change their circumstances, further compounding feelings of worthlessness and humiliation.
In the Dominican Republic, mental health of Haitian migrants is intricately bound to historical processes of differentiation, and especially antiHaitian racism. Countering the institutional and interpersonal dynamics of anti-Haitianism requires a committed effort on multiple fronts. At the institutional level, there must be comprehensive reform of current documentation policies, so that migrants and their descendants can be brought into the larger fold of Dominican society. Equitable social and health policies should address longstanding service gaps in marginalized communities that include both migrants and poor Dominicans. Public education and awareness campaigns could also be implemented to challenge anti-Haitian discourse, inform the public of its harmful effect on mental health and well-being, and emphasize the two countries’ shared customs and values. Such efforts would not be without challenges. Our field study was brief and exploratory in nature, and as such we did not have the time or data analysis completed to begin articulating these forms of intervention. At a minimum, our field project generated cross-cultural dialogue and awareness among both groups of each other’s perspectives on these complicated issues. Our research was highly reflexive throughout the entirety of the project. As a team, we met to discuss findings as they emerged, and in so doing we engaged in self-criticism and reflection, culminating in several presentations at the local public hospital and university. Furthermore, we shared our perspective on anti-Haitian racism and the recent cholera outbreak in a joint letter published in Spanish (Keys et al. 2014). These discussions with audience members and as a team revealed how short-term field projects like ours could at least foster much-needed conversation, in both professional venues like peer-reviewed journals and public health fora, and in the communities where data collection occurs.
This ‘community-level’ experience that we shared as a research team can even be framed as a form of positive contact. ‘Positive contact events’ could assemble both Haitians and Dominicans; such gatherings have been shown in other settings to be effective at reducing prejudicial beliefs held by the dominant group (Pettigrew and Tropp 2006). In this way, global health research, particularly when it is community-based, participatory research (Foster et al. 2015), could serve as an intervention in itself. Positive contact events might gain better traction in these communities if they are modeled on the konbit/convite form of social collaboration. In Haiti, the konbit is a collective gathering of neighbors who join together to accomplish shared tasks; in the Dominican Republic, a similar structure is the convite. As evident in the shared etymological root of konbit/convite, Haitians and Dominicans may find that they share common cultural practices and values, and as such may find a productive and comfortable space to articulate ways of reaching greater social cohesion (Keys et al. 2015). This model of social collaboration may be particularly helpful in this setting, where social interactions between Haitians and Dominicans, and among Haitians themselves, appear to be a source largely of stress rather than support (Kaiser et al. 2015b). Such collaborations can hopefully provide a foundation for future intervention, research, and advocacy.