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A public health framework for reparations and generational healing in Haiti

PMCID: PMC12585046

PMID: 41187124

Abstract

Amid the dismantling of state structures in Haiti, the first Black republic faces significant health disparities compared to its former colonial power, France. These disparities include lower life expectancy (64.8 vs. 82.3 years) and higher infant and maternal mortality rates. The situation is further exacerbated by widespread mental health issues, severe food insecurity (50% acute vs. 37% moderate), and elevated homicide rates (13.35 vs. 1.35 per 100,000 inhabitants). As calls grow for France to return the independence ransoms extracted from Haiti, there remains limited data on how reparations could impact the country’s public health, community well-being, or effective implementation of healing programs. Between Spring and Fall 2023, we conducted 4 focus groups: 1st with Haitian men and women residing in the United States, a 2 nd -with men in Haiti, a 3rd with women in Cap-Haïtien and Les Cayes, and a 4th with women in Cité Soleil. We conducted focus groups structured interview protocol, comprised of open-ended questions categorized into 4 thematic sections. These questions provided insights into participants’ perceptions on mental health, the daily challenges and barriers to access care, and community-based healing. Participants emphasized need for policies that address the social determinants of health, ensure safety and justice, and promote healthier workplace environments. They also advocated for mental health education aimed at reducing stigma, cultivating trust, and strengthening community support systems; with an emphasis on developing professional training, ethics, and sustainable long-term mental health services accessible for individuals of all ages. Haitian participants underscore the critical need to restore security, address the social determinants of health, and implement community-based mental health initiatives. We propose a biopsychosocial-ecological approach to guide reparations efforts. A targeted investment of $30 billion could yield substantial improvements in healthcare, mental health services, and public safety—contributing to increased life expectancy, reduced mortality rates, and decreased violence.

Full Text

Haiti, over 220 years after its independence, continues to struggle with extreme poverty and impoverishment, a situation deeply rooted in historical injustices, anti-Black racism, a colonial legacy, and neocolonialism [1–3]. This includes the colonization by European powers, the genocide of the indigenous Taïno Arawak people, the slave trade, the enslavement of African ancestors, and the crippling economic impact of the reparations indemnity paid to France following the Haitian Revolution. According to eminent French economist, Thomas Piketty, this “double ransom of independence” of 90 million Gold Francs represented three years of Haitian production of 1825 and 300% of current Hait’s GDP or over $US 30 billion [4], deprived Haiti of much of its export revenues, favoring France and draining Haiti’s treasury [5] which severely limited investments in essential sectors like healthcare [4–7].
Over 15 million men, women, and children were victims of the tragic transatlantic slave trade, which lasted approximately 400 years (United Nations, International Decade for People of African Descent; 2015–2024) and is considered one of the greatest genocides in history [8]. Prior to the 1791 revolution, three-quarters of a million captive Africans were dragged to colonial Haiti through the slave trade [9]. Combined with two centuries of enslavement and the ransoms of independence, the repercussions of the slave trade are profound and long-lasting on the mental and physical well-being of Haitians as well as on their political and economic stability, educational system, science, environment, spirituality, and more [10]. Two hundred years after the payment of this independence ransom was ordered, in 2025, Haiti and France present vastly different socio-economic and political realities. As indicated in Table 1, Haiti faces significant challenges in political stability and public health, while France, despite its own challenges, is more developed and stable [11–17]. However, in 2025 amidst the ongoing political crises and the growing demand for France to return the independence ransom to Haiti, there is limited data on how slavery reparations and the ransom restitutions could impact Haiti’s public health and community well-being or how healing programs could be effectively implemented.
Recent scholarship at the intersection of public health and reparative justice has laid critical groundwork for understanding how historical and structural violence contributes to health inequities among marginalized populations. Drawing on this body of work, we argue that any discussion of healing and generational trauma in Haiti must be informed by a reparative public health framework—one that centers the lived experiences of Haitian communities and acknowledges the enduring legacy of colonialism, slavery, and economic exploitation. Several studies have advanced this framework. Richardson et al. (2021) [18] demonstrate how reparative policies for Black American descendants of enslaved people could significantly reduce viral transmission and improve public health outcomes. Soled et al. (2021) [19] further argue for health reparations as an ethical imperative and a pathway to equity, emphasizing the moral and structural failures of existing health systems. Whittaker et al. (2025) [20] build on this by showing how racialized wealth gaps directly shape health disparities, suggesting reparations as a necessary intervention to redress these harms. Similarly, Bassett et al. (2020) [21] make the case for reparations as a public health priority, framing it as a practical and moral strategy for ending racial health disparities. Applying these insights to the Haitian context, we contend that reparations must not be understood solely as financial compensation or state-led acknowledgment of past injustices. Rather, they should encompass a broader, community-informed vision of healing that addresses current material conditions, promotes social and psychological restoration, and invests in public health infrastructure shaped by Haitian voices. Here, we employ a return-on-investment model, proposing preliminary projections for health improvements in Haiti through restitution-based investments totaling $30 billion (Table 1).
In May 2024, as part of the Haiti national reparations committee, we established a task force focused on “Historical/Multigenerational Traumas and Health Reparations.” The goal is to advance reflections and data from a biopsychosocial-ecological (BPSE) perspective on the public health impacts of historical and generational traumas, including the invasion of Ayiti, the lands of high mountains (Saint-Domingue) by Christopher Columbus in 1492, the enslavement of Indigenous and African ancestors, European colonization, and the ransoms Haiti were forced to pay to plantation owners and the State in France, Germany and the United States (U.S) [22–24]. Building on the National Academies of Sciences, Engineering, and Medicine, 2022 & Stineman [25] and Streim, we also aim to explore the modalities of reparations through a health-focused lens (Table 1, Fig 1).
Bassets and Galeo, 2020 [21]
The BPSE model, guided by Health Environmental Integration (HEI), promotes a comprehensive understanding of how illness, injury, limitations in activity, and restrictions in participation arise from the interaction between individuals and their environment. HEI acknowledges that complex, multilevel functional systems operate from the cellular level to an individual’s experience within their environment [22]. The HEI framework offers a holistic approach to understanding the generational traumas associated with slave trade, chattel enslavement, colonialism and human exploitation. In Haiti’s case, centuries of physical and psychological aggression and injuries stemming from race-based slavery and colonial oppression continue to affect the population today [10]. HEI identifies the social and physical environments as crucial in both causing and exacerbating diseases and disabilities. The impoverishment, social inequalities, and lack of healthcare access in Haiti, rooted in colonial exploitation, perpetuate health disparities (see Table – and Fig 1). A global reparations and restitutions movement should therefore go beyond a moral and symbolic recognition and the financial compensation to address these environmental factors that continue to harm the Haitian population.
As the call for slavery reparations to Black populations in the African diaspora, including Haiti, is gaining momentum, our working group aims to explore a wide range of areas that could be tackled within the context of a transnational reparations movement in Haitian communities to promote multigenerational healing and social well-being [26]. In Table 1 and Fig 1, we illustrate this by leveraging a projected impact approach to estimate proportional health improvements based on financial investments in specific Haitian health sectors over time. We compare health disparities between Haiti and France in 2024, projecting improvements in Haiti with a $30 billion independence ransoms restitution investment. Haitian life expectancy could increase from 64.8 to 78–80 years, accompanied by significant reductions in infant and maternal mortality. Significant decreases in infectious diseases like cholera and HIV, along with improvements in chronic conditions such as hypertension and diabetes, are expected. Suicide rates, gender-based violence, and homicide could drop significantly with targeted investments. Healthcare infrastructure would expand, potentially establishing universal coverage for 70–80% of the population within 10–15 years (See Table 1 and Fig 1).
Our Haitian Well-Being Study, a pilot study project aiming mainly to identify psychosocial, neurological, genetic, sleep, physical health, socio-economic (SES), spiritual, and health behavior-related factors associated with mental well-being among a sample of Haitians in the U.S and Haiti, could offer a comprehensive scientific platform to nourish the public health framework of Haiti reparations and restitution movement. For example, through the Haitian Well-Being Study analysis conducted with Haitian men and women across Haiti and the U.S in 2023, we demonstrated the profound impact of Haiti’s deteriorating situation on individual and communal well-being [10]. Participants’ narratives underscore the severe health burden stemming from chronic exposure to socio-political instability, with reports of significant psychological distress and physical health complications such as hypertension, heart conditions, anxiety, substance abuse, suicidal ideations, sleep problems, depression, and post-traumatic stress disorders (PTSD). In this paper, we present the findings of the qualitative assessment that explores insights, guided by Haitian women, men, and caregivers, on how healing can be integrated into both personal lives and the broader Haitian community.
We conducted four focus groups via Zoom with 28 participants from various demographics of the Haitian population, and representing broad perspectives with respect to themes under investigation; details regarding participant demographics and perspectives have been previously described [10]. Participants were located in the western (Port-au-Prince, Cite Soleil), southern (Cayes), northern (Cap-Haïtien), and Artibonite regions (Saint-Marc) of Haiti and the United States. We included Haitian immigrants from the United States, which is home to the most significant Haitian population outside of Haiti. As the crisis in Haiti has worsened over the past five years, more than 400,000 Haitian nationals have entered the United States. This figure includes individuals paroled into the country through a humanitarian program that also offers entry pathways to Cubans, Nicaraguans, and Venezuelans, in addition to those arriving through other immigration channels. As a result, the number of Haitian immigrants in the U.S. has grown substantially, reaching an estimated 852,000 in 2024, according to the Center for Immigration Studies. Both Haitians living in Haiti and Haitian immigrants or refugees residing in the United States have been directly and indirectly affected by the enduring consequences of colonialism, which have significantly contributed to health disparities and adverse health outcomes. They share a collective cultural memory and a unified Haitian identity, expressed through language, socioeconomic ties, and cultural practices aimed at stress reduction and improving overall quality of life. Additionally, many Haitians in the United States maintain strong transnational connections by providing financial support (e.g., remittances), material assistance (e.g., clothing), emotional support (e.g., long-distance communication), and educational resources (e.g., tuition or school supplies). These demographic realities underscore the transnational [10] nature of the Haitian crisis. The lived experiences of this crisis, shared by focus group participants, serve as the foundation for the insights presented in this article and affirm their authority to speak on healing and generational healing within Haitian communities.
Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information (S1 Checklist).
Semi-structured interview guides were used for the focus groups. The focus group guide asked questions about suggestions for healing and moving forward. (See Table 2). The focus groups lasted 60–90 minutes. These sessions were audio recorded. An independent transcription and data management company, Datagain with trained experts in qualitative analysis, transcribed the focus groups. The focus group transcriptions were reviewed by the study’s principal investigator. The transcripts were de-identified and reviewed for accuracy. The transcripts were then translated from Haitian Creole to English by bilingual graduate-level study staff. The independent company analyzed the focus group data using thematic analysis.
Each discussion was guided by a structured interview protocol comprising open-ended questions organized into four thematic sections. These questions were designed to elicit detailed insights into participants’ perceptions of mental health, challenges they face, barriers to accessing care, and community-based healing or coping strategies (See Table 2).
The data were thematically coded using a combination of inductive and deductive approaches. The themes for each question or set of questions were compared and contrasted once combined into a master Excel spreadsheet and reviewed in the context of writing the report. If required, verbatim from the transcripts were re-coded on the spreadsheet. The phrasing of the theme statements in the report was then finalized to provide meaningful summary statements that addressed each specific question or overarching goal, where possible. The first phase was inductive. This was followed by a six-phase [27], deductive analysis by constantly comparing codes and the identification of themes. We conducted verification and legitimacy procedures by investigator triangulation, intercoding, reliability, rigor, and with in-depth descriptions [27,28] which included: (1) familiarization with the data, (2) generation of initial codes, (3) organization of codes into potential themes, (4) review and refinement of themes, (5) clear definition and naming of themes, and (6) final analysis and report production. A specialized codebook, developed specifically for this study, was used to guide the coding process. This codebook provided clear definitions and descriptions for each theme, ensuring consistent interpretation and alignment with participants’ lived experiences [28]. The coding process involved close examination of the content and, where necessary, re-coding of verbatim transcript excerpts within a centralized Excel spreadsheet [28].
To ensure analytical rigor, interrater reliability was assessed qualitatively, and collaborative reviews were conducted among team members to validate the consistency and accuracy of the thematic coding. Discrepancies and concerns regarding interrater reliability were addressed through team meetings, during which analysts collaboratively discussed divergent interpretations and outlined subsequent steps. Final themes and subthemes were determined only after the three analysts conducted a vote and reached unanimous consensus [28–31].
Themes that emerged across different focus groups and questions were systematically compared, contrasted, and refined [30]. The final wording of the thematic statements was developed to provide meaningful summaries that addressed both specific interview questions and the broader aims of the research. The PI adopted a narrative analysis [32] in communicating the findings, allowing for a coherent synthesis of the themes that highlighted key mental health issues, support mechanisms, and the broader social context experienced by the Haitian community.
Before data collection, the study protocol was reviewed and approved by the Institutional Review Board (IRB) of the University of Miami Miller School of Medicine (IRB#: 20211103) to ensure ethical compliance. The approval letter was issued by the University of Miami Human Subject Research Office (HSRO) in November 2022. Participants were recruited through the research team including the study P.I, a native of Haiti’s established networks in the US and Haiti using multiple approaches. Prior to participation, written informed consent was obtained from each individual. Following a screening process, participants provided informed consent online before taking part in focus group discussions. We enrolled participants between April 21st and November 4, 2023. Additional information regarding the ethical, cultural, and scientific considerations specific to inclusiveness in global health research is included in the Supporting Information (See S1 Checklist).
The research team included Haitian and non-Haitian female and male scholars with interdisciplinary backgrounds in public health, psychology, and social justice. Team members with lived experiences in Haitian communities and fluency in Haitian Kreyol contributed to culturally grounded data collection and interpretation. Recognizing our varied positionalities, having advanced degrees ranging from Master’s, PhDs, and Medical Degrees- brought an in-depth critical and self-reflection, that brings an increased awareness to our privilege, status, and power. We drew upon our experiences of struggle, racism, discrimination, inequality, and health disparities’ being in the Caribbean diaspora – while pursuing advanced degrees. According to Horsburg, critical reflection enhances the rigor of the study and ethics since ‘The researcher is intimately involved in both the process and product of the research enterprise, it is necessary for the reader to evaluate the extent to which an author identifies and explicates their involvement and its potential or actual effect upon the findings [33]. We engaged in ongoing reflexive practices to mitigate potential biases and ensure credibility and validity by accounting for researchers ideologies, knowledge, and knowledge production, through trustworthiness and honor of participants’ voices and lived experiences [34–38].
Critical self-reflection and introspection offers many benefits regarding the research process, researcher representation, critical analysis of power dynamics, methods, interpretation, connecting with subjects, boundaries, logistics, requirements, and unexpected matters in conducting research at any given situation [39–41]. Critical self-reflection as researchers, scientists, professors, at elite universities comes with a sense of privilege, however we as authors have experienced directly or indirectly the long standing historical colonial consequences of discrimination and oppression through structural inequalities and inequities. It is understood that although we have advance careers, there are still individuals’ part of the Caribbean diaspora, specifically Haitians, unfortunately who do not have similar opportunities and access to resources to improve their quality of life.
[10] Our discussions on improving mental health support highlighted the importance of addressing social determinants of health, such as housing, financial strain, unemployment, education, and ensuring societal security through justice and crime prevention. Participants emphasized the need for healthy workplace policies, mental health education to reduce stigma and build trust, and comprehensive professional training guided by ethical standards. A recurring theme was the necessity of building sustainable, long-term accessible mental health services to individuals across all age groups. Direct quotes from the participants in English and Haitian Creole are provided in Table 3.
The primary objective of this study was to provide on-the-ground insights into the urgent need for a multigenerational healing movement within Haitian communities, particularly in the context of a state dismantling [10] and the increasing calls for reparations and restitution for slavery. This study utilized the BPSE model, guided by the HEI framework that comprises of comparing current health disparities between Haiti and its former colonial power, France, with a focus on life expectancy, morbidity, and healthcare infrastructure. Additionally, a return-on-investment model was applied to project potential health improvements based on a proposed $30 billion investment in healthcare, public health, and social services. Our focus groups insights align with an April 2024 survey conducted by the Haitian women-led coalition “Rasanble Pou Ayiti,” which gathered responses from over 1,000 participants across Haiti’s ten departments, revealing that psychological support is among the population’s top priorities, alongside security, education, and economic stability [22]. Based on this work, in the Haitian context addressing social determinants of health, establishing mental health services and interventions, improving mental health education, training community leaders and having long-term services are all key elements identified through the use of the HEI framework to consider when formulating plans for reparations, restitution, and generational healing.
This study argues that social determinants of health such as economic instability, lack of education, poor health care access, and security issues must all be addressed for the Haitian community to heal. Extensive literature has examined the role of social determinants of health on poor health outcomes. It has been noted that reparations for Black individuals may help in improving health outcomes [20]. Just as reparations for Black individuals in the US, it may also benefit those living in Haiti.
Focus group participants acknowledged the need for diverse modes of mental health services and programming, including both individualized and collective strategies. Individualized mental health support requires opportunities for personalized, “case-by-case” therapeutic relationships between the provider and the patient. In addition to traditional diagnostic and therapeutic mental health services, participants specifically recognized the importance of strategies that include emotional management, stress management, and behavioral therapy. Research supporting emotion management programs has shown promising results in patients with schizophrenia spectrum disorders, including improved emotion recognition and expression, enhanced connectivity in the amygdala and prefrontal cortex, and overall better quality of life [42–45].
Stress management and coping interventions are gaining attention in immigrant communities, although Haitian communities have not been studied as extensively as other immigrant populations [46–50]. Similarly, behavioral therapies have shown promise in treating PTSD, depression, and related mental health disorders in underserved immigrant populations, though the literature focusing on Haitians is limited [51–56]. Our findings suggest that members of our cohort are aware of the need for individualized mental health services and specific strategies within Haitian communities, which could benefit many community members as they have benefited other international and immigrant communities [10].
In addition to individualized services, participants highlighted the need for collective and community healing and the creation of a supportive environment. Beyond individual needs for personalized approaches, there is a recognized collective need for mental health services support that addresses Haitian communities’ unique challenges and needs. This finding may reflect a core Haitian cultural value of solidarity, often described as tèt ansanm, literally translated as “heads together.” Tèt ansanm has been recognized as a vital, collective source of resilience in the face of struggles common to Haitian communities globally [57,58]. The latter value was well illustrated by a Haiti-based male participant: Nou konnen nou ka konte sou lòt e se de faktè de pwoteksyon e kwayans nou tou, e pafwa li ka menm yon espwa. These mental health services and interventions however would require money and as such reparations could play a significant role.
The need for education and culturally responsive training about mental health and illness was specifically cited as key components of effective mental health care interventions. Focus group participants recognized that some degree of insight and awareness into one’s mental health is required to begin the journey to seek mental health support. Conversely, the stigmatization of mental illness may result from a lack of education about mental health and disease, and educational interventions may provide a means of decreasing stigma-related barriers to seeking mental health care [59–61]. More broadly, access to education and level of education have been linked with mental health care-seeking behavior and access to mental health services, especially in low- and middle-income countries like Haiti and comparable socially disadvantaged populations [61,62].
Culturally adapted approaches have been shown to be more effective and sustainable over time. Culturally adapted mental health care approaches were also identified as important for effective mental health support. Indeed, group therapy and related collective approaches may be more conducive to cultural adaptation in Haitian populations, given the socio-economic and cultural constraints. The limitations of individualized mental health paradigms and the potential value of group or collective mental health approaches have been described in civilian populations affected by war and conflict [63–65]. Moreover, the sustainability of all forms of mental health services, including long-term support for vulnerable populations such as youth and the elderly, was also highlighted as an important need in our focus groups. Collectively, these findings underscore the emergency to prioritize health equity, sustainability, personalized and collective care, and culturally adapted interventions for mental health support and trauma-focused therapy among our Haitian participants. These could all be supported by an influx of additional financial resources.

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"[{\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref001\", \"pgph.0004133.ref003\", \"pgph.0004133.ref004\", \"pgph.0004133.ref005\", \"pgph.0004133.ref004\", \"pgph.0004133.ref007\"], \"section\": \"Introduction\", \"text\": \"Haiti, over 220 years after its independence, continues to struggle with extreme poverty and impoverishment, a situation deeply rooted in historical injustices, anti-Black racism, a colonial legacy, and neocolonialism [1\\u20133]. This includes the colonization by European powers, the genocide of the indigenous Ta\\u00efno Arawak people, the slave trade, the enslavement of African ancestors, and the crippling economic impact of the reparations indemnity paid to France following the Haitian Revolution. According to eminent French economist, Thomas Piketty, this \\u201cdouble ransom of independence\\u201d of 90 million Gold Francs represented three years of Haitian production of 1825 and 300% of current Hait\\u2019s GDP or over $US 30 billion [4], deprived Haiti of much of its export revenues, favoring France and draining Haiti\\u2019s treasury [5] which severely limited investments in essential sectors like healthcare [4\\u20137].\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref008\", \"pgph.0004133.ref009\", \"pgph.0004133.ref010\", \"pgph.0004133.t001\", \"pgph.0004133.ref011\", \"pgph.0004133.ref017\"], \"section\": \"Compelling Statistics Underpinning the Calls for Reparations and Restitutions for Haiti in 2025\", \"text\": \"Over 15 million men, women, and children were victims of the tragic transatlantic slave trade, which lasted approximately 400 years (United Nations, International Decade for People of African Descent; 2015\\u20132024) and is considered one of the greatest genocides in history [8]. Prior to the 1791 revolution, three-quarters of a million captive Africans were dragged to colonial Haiti through the slave trade [9]. Combined with two centuries of enslavement and the ransoms of independence, the repercussions of the slave trade are profound and long-lasting on the mental and physical well-being of Haitians as well as on their political and economic stability, educational system, science, environment, spirituality, and more [10]. Two hundred years after the payment of this independence ransom was ordered, in 2025, Haiti and France present vastly different socio-economic and political realities. As indicated in Table 1, Haiti faces significant challenges in political stability and public health, while France, despite its own challenges, is more developed and stable [11\\u201317]. However, in 2025 amidst the ongoing political crises and the growing demand for France to return the independence ransom to Haiti, there is limited data on how slavery reparations and the ransom restitutions could impact Haiti\\u2019s public health and community well-being or how healing programs could be effectively implemented.\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref018\", \"pgph.0004133.ref019\", \"pgph.0004133.ref020\", \"pgph.0004133.ref021\", \"pgph.0004133.t001\"], \"section\": \"A public health framework for haiti reparations and restitution.\", \"text\": \"Recent scholarship at the intersection of public health and reparative justice has laid critical groundwork for understanding how historical and structural violence contributes to health inequities among marginalized populations. Drawing on this body of work, we argue that any discussion of healing and generational trauma in Haiti must be informed by a reparative public health framework\\u2014one that centers the lived experiences of Haitian communities and acknowledges the enduring legacy of colonialism, slavery, and economic exploitation. Several studies have advanced this framework. Richardson et al. (2021) [18] demonstrate how reparative policies for Black American descendants of enslaved people could significantly reduce viral transmission and improve public health outcomes. Soled et al. (2021) [19] further argue for health reparations as an ethical imperative and a pathway to equity, emphasizing the moral and structural failures of existing health systems. Whittaker et al. (2025) [20] build on this by showing how racialized wealth gaps directly shape health disparities, suggesting reparations as a necessary intervention to redress these harms. Similarly, Bassett et al. (2020) [21] make the case for reparations as a public health priority, framing it as a practical and moral strategy for ending racial health disparities. Applying these insights to the Haitian context, we contend that reparations must not be understood solely as financial compensation or state-led acknowledgment of past injustices. Rather, they should encompass a broader, community-informed vision of healing that addresses current material conditions, promotes social and psychological restoration, and invests in public health infrastructure shaped by Haitian voices. Here, we employ a return-on-investment model, proposing preliminary projections for health improvements in Haiti through restitution-based investments totaling $30 billion (Table 1).\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref022\", \"pgph.0004133.ref024\", \"pgph.0004133.ref025\", \"pgph.0004133.t001\", \"pgph.0004133.g001\"], \"section\": \"A public health framework for haiti reparations and restitution.\", \"text\": \"In May 2024, as part of the Haiti national reparations committee, we established a task force focused on \\u201cHistorical/Multigenerational Traumas and Health Reparations.\\u201d The goal is to advance reflections and data from a biopsychosocial-ecological (BPSE) perspective on the public health impacts of historical and generational traumas, including the invasion of Ayiti, the lands of high mountains (Saint-Domingue) by Christopher Columbus in 1492, the enslavement of Indigenous and African ancestors, European colonization, and the ransoms Haiti were forced to pay to plantation owners and the State in France, Germany and the United States (U.S) [22\\u201324]. Building on the National Academies of Sciences, Engineering, and Medicine, 2022 & Stineman [25] and Streim, we also aim to explore the modalities of reparations through a health-focused lens (Table 1, Fig 1).\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref021\"], \"section\": \"A biopsychosocial-ecological paradigm for reparations and Haitian healing\", \"text\": \"Bassets and Galeo, 2020 [21]\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref022\", \"pgph.0004133.ref010\", \"pgph.0004133.g001\"], \"section\": \"A biopsychosocial-ecological paradigm for reparations and Haitian healing\", \"text\": \"The BPSE model, guided by Health Environmental Integration (HEI), promotes a comprehensive understanding of how illness, injury, limitations in activity, and restrictions in participation arise from the interaction between individuals and their environment. HEI acknowledges that complex, multilevel functional systems operate from the cellular level to an individual\\u2019s experience within their environment [22]. The HEI framework offers a holistic approach to understanding the generational traumas associated with slave trade, chattel enslavement, colonialism and human exploitation. In Haiti\\u2019s case, centuries of physical and psychological aggression and injuries stemming from race-based slavery and colonial oppression continue to affect the population today [10]. HEI identifies the social and physical environments as crucial in both causing and exacerbating diseases and disabilities. The impoverishment, social inequalities, and lack of healthcare access in Haiti, rooted in colonial exploitation, perpetuate health disparities (see Table \\u2013 and Fig 1). A global reparations and restitutions movement should therefore go beyond a moral and symbolic recognition and the financial compensation to address these environmental factors that continue to harm the Haitian population.\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref026\", \"pgph.0004133.t001\", \"pgph.0004133.g001\", \"pgph.0004133.t001\", \"pgph.0004133.g001\"], \"section\": \"A biopsychosocial-ecological paradigm for reparations and Haitian healing\", \"text\": \"As the call for slavery reparations to Black populations in the African diaspora, including Haiti, is gaining momentum, our working group aims to explore a wide range of areas that could be tackled within the context of a transnational reparations movement in Haitian communities to promote multigenerational healing and social well-being [26]. In Table 1 and Fig 1, we illustrate this by leveraging a projected impact approach to estimate proportional health improvements based on financial investments in specific Haitian health sectors over time. We compare health disparities between Haiti and France in 2024, projecting improvements in Haiti with a $30 billion independence ransoms restitution investment. Haitian life expectancy could increase from 64.8 to 78\\u201380 years, accompanied by significant reductions in infant and maternal mortality. Significant decreases in infectious diseases like cholera and HIV, along with improvements in chronic conditions such as hypertension and diabetes, are expected. Suicide rates, gender-based violence, and homicide could drop significantly with targeted investments. Healthcare infrastructure would expand, potentially establishing universal coverage for 70\\u201380% of the population within 10\\u201315 years (See Table 1 and Fig 1).\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref010\"], \"section\": \"A biopsychosocial-ecological paradigm for reparations and Haitian healing\", \"text\": \"Our Haitian Well-Being Study, a pilot study project aiming mainly to identify psychosocial, neurological, genetic, sleep, physical health, socio-economic (SES), spiritual, and health behavior-related factors associated with mental well-being among a sample of Haitians in the U.S and Haiti, could offer a comprehensive scientific platform to nourish the public health framework of Haiti reparations and restitution movement. For example, through the Haitian Well-Being Study analysis conducted with Haitian men and women across Haiti and the U.S in 2023, we demonstrated the profound impact of Haiti\\u2019s deteriorating situation on individual and communal well-being [10]. Participants\\u2019 narratives underscore the severe health burden stemming from chronic exposure to socio-political instability, with reports of significant psychological distress and physical health complications such as hypertension, heart conditions, anxiety, substance abuse, suicidal ideations, sleep problems, depression, and post-traumatic stress disorders (PTSD). In this paper, we present the findings of the qualitative assessment that explores insights, guided by Haitian women, men, and caregivers, on how healing can be integrated into both personal lives and the broader Haitian community.\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref010\", \"pgph.0004133.ref010\"], \"section\": \"Data collection\", \"text\": \"We conducted four focus groups via Zoom with 28 participants from various demographics of the Haitian population, and representing broad perspectives with respect to themes under investigation; details regarding participant demographics and perspectives have been previously described [10]. Participants were located in the western (Port-au-Prince, Cite Soleil), southern (Cayes), northern (Cap-Ha\\u00eftien), and Artibonite regions (Saint-Marc) of Haiti and the United States. We included Haitian immigrants from the United States, which is home to the most significant Haitian population outside of Haiti. As the crisis in Haiti has worsened over the past five years, more than 400,000 Haitian nationals have entered the United States. This figure includes individuals paroled into the country through a humanitarian program that also offers entry pathways to Cubans, Nicaraguans, and Venezuelans, in addition to those arriving through other immigration channels. As a result, the number of Haitian immigrants in the U.S. has grown substantially, reaching an estimated 852,000 in 2024, according to the Center for Immigration Studies. Both Haitians living in Haiti and Haitian immigrants or refugees residing in the United States have been directly and indirectly affected by the enduring consequences of colonialism, which have significantly contributed to health disparities and adverse health outcomes. They share a collective cultural memory and a unified Haitian identity, expressed through language, socioeconomic ties, and cultural practices aimed at stress reduction and improving overall quality of life. Additionally, many Haitians in the United States maintain strong transnational connections by providing financial support (e.g., remittances), material assistance (e.g., clothing), emotional support (e.g., long-distance communication), and educational resources (e.g., tuition or school supplies). These demographic realities underscore the transnational [10] nature of the Haitian crisis. The lived experiences of this crisis, shared by focus group participants, serve as the foundation for the insights presented in this article and affirm their authority to speak on healing and generational healing within Haitian communities.\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.s001\"], \"section\": \"Inclusivity in global research\", \"text\": \"Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information (S1 Checklist).\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.t002\"], \"section\": \"Procedures: Focus group.\", \"text\": \"Semi-structured interview guides were used for the focus groups. The focus group guide asked questions about suggestions for healing and moving forward. (See Table 2). The focus groups lasted 60\\u201390 minutes. These sessions were audio recorded. An independent transcription and data management company, Datagain with trained experts in qualitative analysis, transcribed the focus groups. The focus group transcriptions were reviewed by the study\\u2019s principal investigator. The transcripts were de-identified and reviewed for accuracy. The transcripts were then translated from Haitian Creole to English by bilingual graduate-level study staff. The independent company analyzed the focus group data using thematic analysis.\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.t002\"], \"section\": \"Data analysis.\", \"text\": \"Each discussion was guided by a structured interview protocol comprising open-ended questions organized into four thematic sections. These questions were designed to elicit detailed insights into participants\\u2019 perceptions of mental health, challenges they face, barriers to accessing care, and community-based healing or coping strategies (See Table 2).\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref027\", \"pgph.0004133.ref027\", \"pgph.0004133.ref028\", \"pgph.0004133.ref028\", \"pgph.0004133.ref028\"], \"section\": \"Data analysis.\", \"text\": \"The data were thematically coded using a combination of inductive and deductive approaches. The themes for each question or set of questions were compared and contrasted once combined into a master Excel spreadsheet and reviewed in the context of writing the report. If required, verbatim from the transcripts were re-coded on the spreadsheet. The phrasing of the theme statements in the report was then finalized to provide meaningful summary statements that addressed each specific question or overarching goal, where possible. The first phase was inductive. This was followed by a six-phase [27], deductive analysis by constantly comparing codes and the identification of themes. We conducted verification and legitimacy procedures by investigator triangulation, intercoding, reliability, rigor, and with in-depth descriptions [27,28] which included: (1) familiarization with the data, (2) generation of initial codes, (3) organization of codes into potential themes, (4) review and refinement of themes, (5) clear definition and naming of themes, and (6) final analysis and report production. A specialized codebook, developed specifically for this study, was used to guide the coding process. This codebook provided clear definitions and descriptions for each theme, ensuring consistent interpretation and alignment with participants\\u2019 lived experiences [28]. The coding process involved close examination of the content and, where necessary, re-coding of verbatim transcript excerpts within a centralized Excel spreadsheet [28].\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref028\", \"pgph.0004133.ref031\"], \"section\": \"Data analysis.\", \"text\": \"To ensure analytical rigor, interrater reliability was assessed qualitatively, and collaborative reviews were conducted among team members to validate the consistency and accuracy of the thematic coding. Discrepancies and concerns regarding interrater reliability were addressed through team meetings, during which analysts collaboratively discussed divergent interpretations and outlined subsequent steps. Final themes and subthemes were determined only after the three analysts conducted a vote and reached unanimous consensus [28\\u201331].\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref030\", \"pgph.0004133.ref032\"], \"section\": \"Data analysis.\", \"text\": \"Themes that emerged across different focus groups and questions were systematically compared, contrasted, and refined [30]. The final wording of the thematic statements was developed to provide meaningful summaries that addressed both specific interview questions and the broader aims of the research. The PI adopted a narrative analysis [32] in communicating the findings, allowing for a coherent synthesis of the themes that highlighted key mental health issues, support mechanisms, and the broader social context experienced by the Haitian community.\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.s001\"], \"section\": \"Ethics approval and consent to participate\", \"text\": \"Before data collection, the study protocol was reviewed and approved by the Institutional Review Board (IRB) of the University of Miami Miller School of Medicine (IRB#: 20211103) to ensure ethical compliance. The approval letter was issued by the University of Miami Human Subject Research Office (HSRO) in November 2022. Participants were recruited through the research team including the study P.I, a native of Haiti\\u2019s established networks in the US and Haiti using multiple approaches. Prior to participation, written informed consent was obtained from each individual. Following a screening process, participants provided informed consent online before taking part in focus group discussions. We enrolled participants between April 21st and November 4, 2023. Additional information regarding the ethical, cultural, and scientific considerations specific to inclusiveness in global health research is included in the Supporting Information (See S1 Checklist).\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref033\", \"pgph.0004133.ref034\", \"pgph.0004133.ref038\"], \"section\": \"Positionality statement.\", \"text\": \"The research team included Haitian and non-Haitian female and male scholars with interdisciplinary backgrounds in public health, psychology, and social justice. Team members with lived experiences in Haitian communities and fluency in Haitian Kreyol contributed to culturally grounded data collection and interpretation. Recognizing our varied positionalities, having advanced degrees ranging from Master\\u2019s, PhDs, and Medical Degrees- brought an in-depth critical and self-reflection, that brings an increased awareness to our privilege, status, and power. We drew upon our experiences of struggle, racism, discrimination, inequality, and health disparities\\u2019 being in the Caribbean diaspora \\u2013 while pursuing advanced degrees. According to Horsburg, critical reflection enhances the rigor of the study and ethics since \\u2018The researcher is intimately involved in both the process and product of the research enterprise, it is necessary for the reader to evaluate the extent to which an author identifies and explicates their involvement and its potential or actual effect upon the findings [33]. We engaged in ongoing reflexive practices to mitigate potential biases and ensure credibility and validity by accounting for researchers ideologies, knowledge, and knowledge production, through trustworthiness and honor of participants\\u2019 voices and lived experiences [34\\u201338].\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref039\", \"pgph.0004133.ref041\"], \"section\": \"Positionality statement.\", \"text\": \"Critical self-reflection and introspection offers many benefits regarding the research process, researcher representation, critical analysis of power dynamics, methods, interpretation, connecting with subjects, boundaries, logistics, requirements, and unexpected matters in conducting research at any given situation [39\\u201341]. Critical self-reflection as researchers, scientists, professors, at elite universities comes with a sense of privilege, however we as authors have experienced directly or indirectly the long standing historical colonial consequences of discrimination and oppression through structural inequalities and inequities. It is understood that although we have advance careers, there are still individuals\\u2019 part of the Caribbean diaspora, specifically Haitians, unfortunately who do not have similar opportunities and access to resources to improve their quality of life.\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref010\", \"pgph.0004133.t003\"], \"section\": \"Results\", \"text\": \"[10] Our discussions on improving mental health support highlighted the importance of addressing social determinants of health, such as housing, financial strain, unemployment, education, and ensuring societal security through justice and crime prevention. Participants emphasized the need for healthy workplace policies, mental health education to reduce stigma and build trust, and comprehensive professional training guided by ethical standards. A recurring theme was the necessity of building sustainable, long-term accessible mental health services to individuals across all age groups. Direct quotes from the participants in English and Haitian Creole are provided in Table 3.\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref010\", \"pgph.0004133.ref022\"], \"section\": \"Discussion\", \"text\": \"The primary objective of this study was to provide on-the-ground insights into the urgent need for a multigenerational healing movement within Haitian communities, particularly in the context of a state dismantling [10] and the increasing calls for reparations and restitution for slavery. This study utilized the BPSE model, guided by the HEI framework that comprises of comparing current health disparities between Haiti and its former colonial power, France, with a focus on life expectancy, morbidity, and healthcare infrastructure. Additionally, a return-on-investment model was applied to project potential health improvements based on a proposed $30 billion investment in healthcare, public health, and social services. Our focus groups insights align with an April 2024 survey conducted by the Haitian women-led coalition \\u201cRasanble Pou Ayiti,\\u201d which gathered responses from over 1,000 participants across Haiti\\u2019s ten departments, revealing that psychological support is among the population\\u2019s top priorities, alongside security, education, and economic stability [22]. Based on this work, in the Haitian context addressing social determinants of health, establishing mental health services and interventions, improving mental health education, training community leaders and having long-term services are all key elements identified through the use of the HEI framework to consider when formulating plans for reparations, restitution, and generational healing.\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref020\"], \"section\": \"Social determinants of health\", \"text\": \"This study argues that social determinants of health such as economic instability, lack of education, poor health care access, and security issues must all be addressed for the Haitian community to heal. Extensive literature has examined the role of social determinants of health on poor health outcomes. It has been noted that reparations for Black individuals may help in improving health outcomes [20]. Just as reparations for Black individuals in the US, it may also benefit those living in Haiti.\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref042\", \"pgph.0004133.ref045\"], \"section\": \"Mental health services and interventions\", \"text\": \"Focus group participants acknowledged the need for diverse modes of mental health services and programming, including both individualized and collective strategies. Individualized mental health support requires opportunities for personalized, \\u201ccase-by-case\\u201d therapeutic relationships between the provider and the patient. In addition to traditional diagnostic and therapeutic mental health services, participants specifically recognized the importance of strategies that include emotional management, stress management, and behavioral therapy. Research supporting emotion management programs has shown promising results in patients with schizophrenia spectrum disorders, including improved emotion recognition and expression, enhanced connectivity in the amygdala and prefrontal cortex, and overall better quality of life [42\\u201345].\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref046\", \"pgph.0004133.ref050\", \"pgph.0004133.ref051\", \"pgph.0004133.ref056\", \"pgph.0004133.ref010\"], \"section\": \"Mental health services and interventions\", \"text\": \"Stress management and coping interventions are gaining attention in immigrant communities, although Haitian communities have not been studied as extensively as other immigrant populations [46\\u201350]. Similarly, behavioral therapies have shown promise in treating PTSD, depression, and related mental health disorders in underserved immigrant populations, though the literature focusing on Haitians is limited [51\\u201356]. Our findings suggest that members of our cohort are aware of the need for individualized mental health services and specific strategies within Haitian communities, which could benefit many community members as they have benefited other international and immigrant communities [10].\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref057\", \"pgph.0004133.ref058\"], \"section\": \"Mental health services and interventions\", \"text\": \"In addition to individualized services, participants highlighted the need for collective and community healing and the creation of a supportive environment. Beyond individual needs for personalized approaches, there is a recognized collective need for mental health services support that addresses Haitian communities\\u2019 unique challenges and needs. This finding may reflect a core Haitian cultural value of solidarity, often described as t\\u00e8t ansanm, literally translated as \\u201cheads together.\\u201d T\\u00e8t ansanm has been recognized as a vital, collective source of resilience in the face of struggles common to Haitian communities globally [57,58]. The latter value was well illustrated by a Haiti-based male participant: Nou konnen nou ka konte sou l\\u00f2t e se de fakt\\u00e8 de pwoteksyon e kwayans nou tou, e pafwa li ka menm yon espwa. These mental health services and interventions however would require money and as such reparations could play a significant role.\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref059\", \"pgph.0004133.ref061\", \"pgph.0004133.ref061\", \"pgph.0004133.ref062\"], \"section\": \"Mental health education\", \"text\": \"The need for education and culturally responsive training about mental health and illness was specifically cited as key components of effective mental health care interventions. Focus group participants recognized that some degree of insight and awareness into one\\u2019s mental health is required to begin the journey to seek mental health support. Conversely, the stigmatization of mental illness may result from a lack of education about mental health and disease, and educational interventions may provide a means of decreasing stigma-related barriers to seeking mental health care [59\\u201361]. More broadly, access to education and level of education have been linked with mental health care-seeking behavior and access to mental health services, especially in low- and middle-income countries like Haiti and comparable socially disadvantaged populations [61,62].\"}, {\"pmc\": \"PMC12585046\", \"pmid\": \"41187124\", \"reference_ids\": [\"pgph.0004133.ref063\", \"pgph.0004133.ref065\"], \"section\": \"Long-term services for all generations and genders\", \"text\": \"Culturally adapted approaches have been shown to be more effective and sustainable over time. Culturally adapted mental health care approaches were also identified as important for effective mental health support. Indeed, group therapy and related collective approaches may be more conducive to cultural adaptation in Haitian populations, given the socio-economic and cultural constraints. The limitations of individualized mental health paradigms and the potential value of group or collective mental health approaches have been described in civilian populations affected by war and conflict [63\\u201365]. Moreover, the sustainability of all forms of mental health services, including long-term support for vulnerable populations such as youth and the elderly, was also highlighted as an important need in our focus groups. Collectively, these findings underscore the emergency to prioritize health equity, sustainability, personalized and collective care, and culturally adapted interventions for mental health support and trauma-focused therapy among our Haitian participants. These could all be supported by an influx of additional financial resources.\"}]"

Metadata

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