Why Haitian Refugee Patients Need Trauma-Informed Care

Owing to its grappling with a motley of intricate socioeconomic, as well as medico-legal, crises, Haiti has found itself bereft of some of its people, many of whom have had to leave the Caribbean country in search of improved lives elsewhere. Receiving some of the Haitian refugees fleeing abject poverty, unemployment, and other harms and barriers has been the United States, one of Haiti’s northern neighbors and a country that has played an outcome-determinative, if not outsized, role in steering the country toward its presently hobbled state. Drawing on the U.S.’s recent treatment of Haitian refugees, this paper argues that U.S. re-ception of Haitian immigrants rubs salt in the wound of a long history of dehumanizing and oppressive abuses endured by Haitians. Furthermore, and more importantly, this paper posits that U.S. failure to wholly embrace its legal obligation to accept Haitian refugees under international law needs to be understood in the light of the specific horrors inflicted by science, in pre-independence Haiti, on non-consenting, Afro-Haitian experimental subjects. And by extension, such a contextually-nuanced understanding is crucial in shaping the delivery of healthcare services to Haitian refugees fortunate enough to remain in the U.S. —as an awareness and appreciation of the socio-historical context of patients’ lived experiences, i.e., their complete social history, can furnish important clues vis-à-vis the presence and etiologies of disease, influence the foci of physical exams, and generally pave the way for the provision of cost-efficient and evidence-based care.


Introduction
Since mid-September 2021, roughly 15,000 (Chappell, 2021, September 24) wouldbe refugees and asylees, mostly Haitians, had reached American soil, in Del Rio, Texas (The White House, 2021), after having risked their lives, and abandoned their livelihoods, to flee violence and discrimination (Dobbins et al., 2021).To date, almost 4,000 Haitians, some of them children with "non-Haitian passports (Hu, 2021)," have coped with forcible returns to Haiti, and about 8,000 went back to Mexico "voluntarily (Constantino, 2021)."Many of the remaining people are slated to face deportation carried out under the Title 42, §265 (United States Code, n.d.), emergency public health law.
During recent times, multiple scholars, activists, and public servants have intensely criticized American president Joseph Biden administration for its treatment of Haitian immigrants.Notably, Ambassador Daniel L. Foote (U.S.Department of State, 2021), Special Envoy for Haiti, resigned on account of not wanting to "not be associated with the United States['] inhumane, counterproductive decision to deport thousands of Haitian refugees," given "the danger posed by armed gangs in control of daily life" in Haiti (Shear et al., 2021).Foote's resignation echoes the sentiments felt by many -who have argued, in essence, that Biden is toeing the realpolitik (or tough, amoral, and cynical), line embraced by his Republican and Democratic predecessors.Other allegations, expressed by U.S. Congresswomen Maxine Waters and Ayanna Pressley as well as Vice President Kamala Harris (Logan, 2021), have compared border agents' "corralling" of Haitian immigrants to slave hunting (NBC News, 2021, September 21).
While such comparisons may be apt, the recent treatment of Haitian immigrants needs to be understood in the light of the specific horrors inflicted by science, in preindependence Haiti, on non-consenting Afro-Haitian experimental subjects.Such understanding is crucial in shaping the delivery of healthcare services to Haitian refugees who remain in the U.S. Awareness of, and sensitivity to, this history, especially from the perspective of healthcare practitioners, will only increase the effectiveness of any future patient care delivery.

Polishing the Pearl
Nearly 240 years ago, enslaved Afro-Haitians toiled on cotton fields and coffee plantations in fueling a lucrative and robust economic engine.Historians and other experts agree, almost exclusively, that Haiti was the wealthiest and most productive colony (The John Carter Brown Library, n.d.-b) in the world throughout the 1780's.While bearing the name Saint-Domingue (Ghachem & Danforth, n.d.) and facing inhuman subjugation, 18th-century Haitians led world markets, in producing loads of coffee and sugar, highly-valued (Trouillot, 1982) crops, and majorly (Trouillot, 1982) exporting cacao, cotton, and indigo (The John Carter Brown Library, n.d.-b).For this level of Eurocentrically-prized productivity, Haiti was known, throughout much of the 1700's, as a distinctly successful colony that the French and other Western Europeans had lionized as the "Pearl of the Antilles (Munford, 1991)," or Caribbean islands.
In Saint-Domingue, slave labor proved central."Roughly 8000 plantations (George A Smathers Library, n.d.) ("habitations") prospered . . .entirely dependent on slavery."Later on, in a piecemeal, yet far-reaching turn of events, Haiti dealt France a bitingly painful blow.In 1804, the country defeated French colonial forces and declared independence (PBS International, n.d.), after shockingly winning a multi-year (The Blackest Panther, 2017, February 4) struggle against one of the "most belligerent" (Neal, 2002) of the world's "great powers."Interestingly, given Haiti's distinguished and odds-defying past -not only as a slave-fueled economic engine but also as the world's first Black-led republic -the country's present positioning in a multi-angled economic and political vise may raise some questions.
Haitian nationals fleeing their homeland may further compound the questionasking.
In an important way, and of relevance to the discussion that follows, Haiti was also "the major center of organized and institutionalized science (McClellan III, 2010a) and medicine in the western hemisphere at the end of the eighteenth century" writes science historian James McClellan (Horgan, 2013, April 15).
At the source of Haiti's scientific prowess (Gorelick, 2013) were three groups.In one camp were the Afro-Haitian slaves, in the agonizing, sacrificial role of experimental subjects.And, in another, opposite camp were the comfortable, French-trained legal and healthcare professionals (often from Université de Montpellier) (McClellan III & Meli, 1992), who one-sidedly enjoyed the many fruits of Haitian slave labor.A third, and final, group (Weaver, 2002) consisted of "Enslaved healers including herbalists, kaperlatas [female spiritual and natural medicine practitioners] . . .and accoucheuses [midwives] . . .[who] flourished in the medical world of Saint Domingue . . . .[and] were responsible for the creation of an indigenous form of medicine on the island."Because of their Blackness, these practitioners had to operate at the margins of colonial Haitian society, as their colonizers had placed a ban on their craft, as detailed below.
Given the healers' treatment of (Weaver, 2006) and thus valued, cross-communal relationships (Sano, 2007) with enslaved Afro-Haitians and Creoles, or mixed-race people, as well as plantation owners, this occupational group occupied an influential and somewhat feared position, particularly in view of the widespread fear of poisonings across 18th century Haiti.
Ultimately, despite the importance of this third group, its subversive work and healing will not be portrayed below.Instead, this work will remain focused on the relationship between the two other groups, in capturing the medico-scientific exploitation of 18th century Afro-Haitians.
In this vein, for the supposed benefit of advancing scientific knowledge, colonial French, if Franco-Haitian, doctors (Arthaud, n.d.), other experts, and scientificallyuntrained slave owners sacrificed Afro-Haitian bodies, by subjecting them to horrifying experimentation (Little, 2020).This medico-scientific denial of Haitian human agency mirrored colonizers' violation of Afro-Haitian self-determination, in forcing Haitian people to work without pay and withstand all attendant injustices for the benefit of France and French citizens.

Black Body Experimentation
Through the 1697 Treaty, or Treaties, of Ryswick (Steenhard, 2017, August 17), France had gained control, from Spain, of the island of Hispaniola, of which Haiti is, in 2021, a territorial third.From that time forward, the Caribbean country went on to suffer a brutal, and yet highly profitable (Geggus, 2012), system of slavery, which led to high cash crop productions, as mentioned above.
Availing themselves of the unpaid labor provided by Afro-Haitians, French colonists established a multiracial order (Garrigus, 2006), whose upper echelons encompassed persons whose lineage came closest to Whiteness, with Black-skinned African descendants forced to the bottom.Within this racially-ranked society, medical scientists had instituted brutal medical experimentation on Black bodies (Arthaud, 1791), using support from the French government and French high society.This happened some years before Haiti had launched a multi-year war that allowed it to win its independence from France.
Named the Cercle des Philadelphes, French for "Circle of Philadelphians," this experimental and scientific society worked at the forefront (McClellan III, 2010b) of Western science.In roughly signifying, by name, "men devoted to common happiness (Maurel, 1961) and are mindful that brotherly love should be a sentimental priority," the Cercle's name is etymologically derived from the Greek term that denotes "brotherly love."To boot, per historian McClellan, when the effects of its undertakings were multiplied by the above-discussed cultural offerings found in 18th-century Haiti, the Cercle found itself benefitting from a culturo-scientific driving force.
Interchangeable with Cap-Français (or "French Cape"), and as the forerunner of today's Cap-Haïtien (or "Haitian Cape"), Cap François, a third and synonymous name for the same Northern Haitian city, uniquely exhibited Haiti's cultural refinement.Cap François had, for instance, more residents (The John Carter Brown Library, n.d.-a) than Boston -which was at the time "a successful colony (Brooks, 2011, July 23) with a large trade industry" and has been one of the "three largest cities (Glaeser, 2005) in colonial America [to] remain at the core of three of America's largest metropolitan areas."Specifically, Cap François's 18th-century cultural assets gave Haiti a collection of theaters, orchestras, and operas, as well as a thriving print culture (The John Carter Brown Library, n.d.-a).In describing this presumably fruitful culturo-scientific period, McClellan writes that, "Cap François and the Cercle des Philadelphes certainly rivaled, if not eclipsed (Meade & Walker, 1991) Philadelphia with its American Philosophical Society (1768) and Boston with its American Academy of Arts and Sciences (1780), the two major scientific centers in the United States."And for part of this period, the U.S. figured as Britain's prized colonial possession.
To better understand the weight of McClellan's statement, it is worth considering that the 18th-century was part of the Western Hemisphere's Age of Enlightenment (Hankins, 1985).During this era, the first scientific societies had sprung into creation while major intellectual traditions, like Aristotle's philosophy (Bristow, 2017) and ancient medical theories (like humorism, assigning (Emtiazy et al., 2012) to the human body four humors (Richet, 1910): blood, black and yellow biles, and phlegm), were undergoing displacement (Goupil, n.d.).
The Age of Enlightenment was also defined by scientific reasoning starting to take over (Lewes, 1864) from religious authority.In consequence, some disciplines -like astrology (believing celestial body motions have the capacity to shape the outcome of human affairs) and alchemy (believing base metals can be turned into gold and cure-alls can be discovered) -started to forfeit their scientific tenability (Hanegraaff, 2013).
At its core, aside from valuing rational thought and embracing knowledge anchored in evidence and sense-experience (Bristow, 2017), Enlightenment science prioritized progress (Keohane, 2020).While some thinkers, like Jean-Jacques Rousseau (Bertram, 2020), found fault with the sciences (Rousseau, 2009) and early modern society for separating "man" (Garrard, 2003) from "his" amour de soi même, or love of self, the 18th century served as an influential period (Compton, 1956) for Western science.
Of relevance to the Cercle is the fact that, throughout the Enlightenment and 18th century, scientific academies, and societies, instead of universities (McClellan, 1985), led the popularization, if not the pursuit, of scientific knowledge.
Another influential development consisted of science becoming increasingly accessible to the masses, in light of the accompanying rise of literacy (Houston, 1983) and cross-border sharing of scientific works through translations (Boissoneault, 2019).
In sum, given the above reasons, the 18th century facilitated notable advancements (Del Negro, 2006) in a variety of scientific fields, ranging from physics to medicine.

Zooming In On The Cercle
Given Haiti's socio-scientific alignment with the innovative forces that drove that period, colonial French scientists felt they had reason to, and could, exploit enslaved Afro-Haitians, in pursuing the Cercle's scientific objectives.Ultimately, supporting the Cercle's scientific stature happened to also match the self-serving aim of contributing to the institutional forces that facilitated Haiti's colonial development.
At the heart of the Cercle's activities were widely-varied (Cercle des Philadelphes, n.d.) and dehumanizing experiments.In this context, experimentation can be understood to have entailed a set of steps undertaken by Cercle members to engage in discoveries, evaluate hypotheses, or prove established facts.
In presenting the goal of its experiments, the Cercle maintains, in its 1786 Essay and observations on tetanus (Arthaud, n.d.), that "We are not extending our research to all seizure types."Instead, the Cercle chose to limit its experimental work and discussions to conditions "known in Saint-Domingue under the names of spasm or tetanus, and of what is called jaw pain in children; a type of tonic spasm [or fit of muscle contraction] that always presents the phenomena of opisthotonos [partly marked by backward arching of the neck and spine]."These limitations strongly supports the idea that the Cercle thought of its work as being experimental in formalizing a conceptual scope and using medico-scientific terminology.
In defense of the Cercle, one could argue that the scientific society's activities were somewhat similar to today's clinical research initiatives, which are performed to improve patient care and advance scientific knowledge.In a limited way, this view has merit.However, it is hopelessly incomplete -in failing to consider the 18th century realities and nuances of the doctor-patient relationship.

Masking Abuse as Science
Undoubtedly, the way Cercle associates treated vulnerable 18th century Afro-Haitians fundamentally clashed with 18th century norms relating to the doctor-patient relationship.Throughout that century (Kaba & Sooriakumaran, 2007), "Doctors were few in number and their patients mainly upper class and aristocratic."With few doctors, although economic theory would suggest that there would be minimal competition, the opposite was true.Doctors and their patients were on unequal footing.The difference in status between the two groups "ensured the supremacy or dominance of the patient" and doctors in turn "had to compete with each other in order to please the patient."In other words, patients' material means afforded them major control over who they wanted to care for them, leaving doctors to strive against one another in staying in patients' employ.Unlike the privileges accorded to grands and petits blancs, supposedly highand low-status White patients, Haiti's Afro-Haitian slaves faced inhuman treatment.
Fundamentally, in masking abuse as science, Cercle investigations, as part of the White-controlled medical establishment, adversely harmed the non-consenting Haitian adults and children on whom they were performed.

Conclusion
In view of the above history, anchored in systematic and scientific oppression, Afro-Haitians' past trauma might have an effect that has reverberated (Sotero, 2006) across generations.Although healthcare practitioners should be aware of how history informs the present, they should refrain from perceiving Haitians as being fundamentally or genetically flawed, in view of Haiti's traumatic past.Instead, Haitian history provides a generationally-transferrable framework within which some Haitians can and do interpret modern-day phenomena.
In other words, present-day Haitians, like other historically-marginalized groups (Carnethon et al., 2017), can show health-affecting (Albert et al., 2013) signs and symptoms, tied to trauma, that are socially-created, or cultivated -which can in turn influence the care that they receive.
Counterarguments pointing out that most Haitians are unaware of the Cercle's horrifying activities, therefore making an awareness of this historical trauma by medical personnel unimportant, are misconceived.The trauma caused by Cercle members is part of a compounded intergenerational harm caused by decades of pre-independence slavery, post-independence isolation of Haitian society, and institutionalized racism committed against Haitian institutions and people.Multiple books (Thompson-Miller & Ducey, 2017) and articles (Liberato & Jean, 2017) have presented the evidence or supported the arguments needed to more strongly make this last point.
The physical and psychological trauma caused by Cercle members also enjoys renewal through the daily reminders of ongoing discrimination committed against Haitians, within Haiti as well as throughout diasporic communities (Dubois, 1996) in the Dominican Republic (Faugas, 2021), France (France 24 English, 2019, June 19), the U.S. (Hudson, 2018) and South-America (Center for Gender & Refugee Studies, 2021).
Above all, modern medicine and science recognize the importance of delivering trauma-informed care (Albert et al., 2017), regardless of ancestral history, thereby supporting this work's central argument.Important steps in delivering traumainformed care include meeting "in a safe, collaborative, and compassionate manner; preventing treatment practices that retraumatize people with histories of trauma," as well as attempting to cultivate patients' strengths "in the context of their environments and communities."In consequence, practitioners delivering healthcare services to Haitians should be aware of the above socio-medical history and take steps to provide them access to culturally-competent, trauma-informed care.These practitioners should also take bias-countering and other measures in doing away with the adverse, anti-humanist consequences of a world history that has privileged the interests of certain racialized groups at the detriment of other racialized identities.