Editor’s note: In June, Americas contributor Rupa Chinai toured Haiti as part of a group of reporters covering access to healthcare. The food crisis that led to widespread demonstrations in Haiti has been covered widely in the mainstream press and in these pages. Much less well-known is the silent crisis in healthcare that is claiming lives and crippling future generations. Both crises have the same roots: the loss of food sovereignty and the basic ability of a nation to feed its own people.
Haiti today is a tragic case study of how developing nations can lose the sovereign right to ensure access to healthcare when they lose their right to local food self-sufficiency under globalization.
As I traveled throughout rural Haiti looking at access to healthcare, it quickly became apparent that there is an absence of resources and political will—both nationally and internationally—to resolve fundamental health problems. Critical challenges to build its basic healthcare infrastructure, create a knowledge and skills base within its human resources, and produce nourishing food that will sustain the health and economic survival of its poor remain unmet, and in many cases, unaddressed.
Dying in Jacmel
An examination of healthcare services at a public hospital in the rural town of Jacmel (capital of the Department of Sud-Est in Haiti) provides insight into on-the-ground reality. At the women’s ward within this hospital the nuns—the only caregivers seen—watch in despair as women writhe in pain, slip in and out of coma, or lie bleeding profusely. The hospital does not provide free life-saving drugs and the women are too poor to buy them.
The Jacmel public hospital is situated in the middle of the department, along the coast, and serves a population of 500,000. People living on the eastern and western flanks or the hilly hinterland lack easy access to it. There are no roads or public transportation. Patients coming from the periphery have to travel up to eight hours by boat to reach Jacmel. The ticket costs US$8, while the average Haitian earns $50 per month.
But even if patients reach the Jacmel hospital, there is no guarantee that services will be available. The last surgeon to work at this hospital left in 2004. There has been no anesthetist at the hospital for over a month and no obstetrician since 2006. Doctors are not paid and many are unwilling to work here. The doctors lack regular salaries, equipment, and support.
When questioned in an interview in the capital city of Port-au-Prince, Haiti’s Minister of Health and Population Dr. Robert Auguste said the government offers free obstetric care at its "labor centers" and women can approach "health promoters" for free drugs. So why are these not housed within the only public hospital in all of Jacmel? I received no clear answers.
"We are still dealing with a very difficult situation in terms of providing healthcare to the people," Dr. Auguste says. "But we are coordinating with international donors and organizations to improve Haiti’s healthcare system. Haiti has lived with more than 20 years of disorder and we are starting to rebuild our nation," he says.
According to Haitian NGOs, government agencies are not providing basic life-saving drugs. While the World Health Organization provides some general drugs, the bulk of Haiti’s donors focus exclusively on HIV-AIDS drugs.
Haiti has only one doctor per 10,000 people in its entire population. A large number of Haiti’s medical professionals have left the country to work elsewhere and the country now depends on Cuba for trained doctors. Haiti and Cuba have a 10-year cooperation agreement for development of Haiti’s medical professionals. Haitian doctors trained there have to promise to give 10 years of government service but up to half refuse to come back or move to work in the United States.
For three weeks running, the Jacmel hospital has been without electricity following the breakdown of the overloaded generator and the absence of any back-up. The town’s gasoline-based electricity supply has deteriorated. Consumers cannot pay for the rise in fuel costs and so supply is restricted to barely two hours a day—if they are lucky. During our four days in Jacmel, the city never had electricity. There is only one ambulance at the Jacmel Hospital, which is supposed to serve the entire department.
Haiti’s main health problems relate to high maternal and infant mortality, TB, HIV-AIDS, malaria, infectious diseases, high blood pressure, and dental problems, notes Deslouches Gaston, Jacmel Department’s director of health services.
"Human resources and everything else are kept in Port-au-Prince," admits Dr. Gaston. But patients cannot travel directly to the capital for treatment. Even though severely sick, they are forced to lose two days to come first to the Jacmel Hospital and obtain a referral. The elite of Haiti seek services in neighboring Dominican Republic or in the United States. The rest, like the women in the women’s ward of Jacmel Hospital, have little option but to lie down and die.
Relationship between the Food and Health Crises
Patients seek professional healthcare as a last resort. Apart from the issues of access, only those with money can make timely decisions to go to a healthcare facility. Haiti’s high maternal mortality rate—630 per 100,000—is mainly due to anemia, which leads to pregnancy-related complications such as eclampsia and hemorrhage and the birth of low birth-weight babies, and can be easily treated if caught in time.
Haiti’s infant mortality rate is 87 per 1,000 for children under five years of age and 53 per 1,000 for those under age one, says UNICEF’s Haiti office. The main causes of death are pneumonia and diarrhea.
"In the regional context, it is a very bad situation," says a UNICEF spokesperson in Haiti, Dr. Teresa de la Torre, chief of health and nutrition. "There is no country in the Americas region which has comparable indicators. The maternal mortality rate is comparable to the worst in African countries. There is extreme vulnerability because of poor nutrition," she says.
UNICEF points to studies that show 23% of Haiti’s children suffer from "chronic" malnutrition while nine 9% are "acutely" malnourished. In some areas of Haiti "acute malnutrition" has reached 10%, a mark that warrants pulling the "emergency trigger," according to international standards, says UNICEF.
Chronic malnourishment is widespread in Haiti and an underlying cause of other illnesses. It affects the long-term development and potential of the child. By age two, its impact on the child cannot be reversed. Acute malnutrition is recognized by bow legs, swollen stomach, and thin limbs. These arise from lack of nutritious food, basic staples, and micro-nutrients. Young women need access to such food long before they become pregnant; interventions during pregnancy are too late. International studies have revealed the link between low birth-weight babies and heart disease in adulthood.
Even the World Bank (not known for its concern for social indicators) refers to chronic malnutrition in Haiti as the "main hurdle" in bringing the country out of poverty, the UNICEF spokesperson pointed out.
UNICEF’s efforts for children in Haiti revolve around vaccination, conducting surveys, and preparations to promote "therapeutic food." This is a ready-to-eat food supplement made from milk, peanuts, and added chemical micro-nutrients. "It is seen to be a drug and should be used in a certain way—in specific amounts and a certain rhythm. It is a treatment and it is important that it remains as such," UNICEF clarified.
Health agencies working in Haiti, including UNICEF, are clear that drugs and food therapies do not address the key issues—the national production of food and restoration of agricultural self-sufficiency.
"We are not paying attention to the national production of food. We are importing everything, including bananas and citrus fruits from the Dominican Republic. During the 1950’s Haiti used to feed the other Caribbean islands. We have not given importance to developing its potential over the last many years," says Elisabeth Augustin, a Haitian who works with an international aid agency.
Apart from the Cubans, European and Canadian aid agencies have sought to address the long-term development of Haiti’s healthcare services by focusing on maternal and child health. They have donated to the development of primary healthcare, salaries, training of community healthcare workers and local midwives, and materials for preventive education.
This effort however is restricted to five small-scale projects spread across the country. It does not cover Jacmel. Meanwhile some individual philanthropists in the United States support Haiti’s orphanages, but the majority of the 200,000 orphan children receive no organized support, according to UNICEF.
HIV-AIDS in the Context of the Health Crisis
The bulk of aid money coming into Haiti focuses on HIV/AIDS and involves "very big players" for whom "money is not a problem," says UNICEF. At the forefront is the U.S. government, which is Haiti’s biggest donor, and a major supplier of pharmaceutical drugs. Much of this money, however, is ploughed back to U.S. industries, which have heavily invested in HIV/AIDS drugs and diagnostics.
The Bush government initiated the "President’s Emergency Plan for AIDS Relief" (Pepfar). The program provides Anti-Retroviral (ARV) drugs and the diagnostic kits for detection of HIV/AIDS. While the number of HIV/AIDS affected in Haiti was projected to be 5% in 1989, it was recently scaled down to 2.3% following more comprehensive community studies.
The life-long ARV regimen requires strong laboratory support for regular monitoring of patients on the drug. It also needs highly trained technicians who can ensure accurate results. Both are exceedingly scarce in Haiti. And while ARV helps to prolong life, it does not offer a cure and there is no evidence of how it helps malnourished populations with a heavy burden of disease who cannot survive on tablets alone. The United States meanwhile provides no guarantee that the free provision of these expensive ARV drugs will continue indefinitely for patients already launched on the regimen.
"Haiti’s family planning program also started like this," says Marie Mercy Zevllos, director of the Hope Centre, which provides AIDS counseling. "Initially we received all the support—technical and financial. But then when the government changed in the United States, the program ended. The current approach is good for the pharma industry in the United States—it is helping Haitians, but it also seeks to help themselves."
The concern with providing Haiti with AIDS drugs has not extended to other life-saving drugs that affect the vast majority of the population. Even drugs for the AIDS-related "opportunistic infections" such as TB or diarrhea are neglected. And even while the rising disease graph points to a host of health problems and the healthcare system lies in shambles, the government, along with its U.S.-sponsored AIDS lobby, claims a "success story" in bringing down HIV/AIDS in Haiti.
Also missing in the AIDS-dominated discourse on Haitian health is the vital role of locally-produced nutritious food, clean water, and sanitation, and the difference it would make to diseases across the board. A Haitian working in the U.S. Embassy’s visa department reported that she is seeing an increasing number of poor people who are suffering from "strange diseases that are arising because of poor nutrition." They are being helped by some U.S.-based NGOs to get treatment in their country. They have symptoms such as cancer or skin lesions or water retention in the brain. Those who cannot get support have no choice but to die, she said.
Traditional and Grassroots Alternatives May Hold Answers
Voodoo, a traditional healing practice and religion brought to Haiti by the first African slaves, is a major force in the lives of Haitians. Although it is officially recognized, it has not received much government support, complains Celestin Saummervil, a voodoo priest. According to him, Voodoo and use of traditional medicines play an important role in curing certain health problems and should be tried before seeking modern medicine.
Saummervil says that traditional healers have received training from professional doctors and they do refer patients to hospitals, but the collaboration is only one-way, since the Christian church opposes voodoo. While voodoo can use "black magic" to cause harm, most voodoo priests believe that it must be used to protect and help people and "work for the good," he stressed.
"The situation faced by rural patients is pitiable for they have no access to modern medicine and the government is not helping them. We feel bad because we cannot do everything that we want to do for them," Saummervil added. While the Haitian government recognizes the importance of developing herbal medicines, it has not been able to offer substantial support for their development, given the plethora of its priorities.
Short on trained medical personnel and subjected to constant political instability, the Haitian government has not been able to plan beyond the "emergency mode." In this situation, one hope lies in the emergence of community-based organizations that are beginning to take charge by understanding the factors that would sustain their own health and environment.
One such initiative was evident in Marigot. There local youth organizations are planting trees. Reforestation is key to holding topsoil, and rejuvenating soil fertility to ultimately restore local food sufficiency. In Port-au-Prince, a slum community revealed how technical and financial support from India, Brazil, and South Africa is helping them run a pilot project for the creation of fuel briquettes from waste. This initiative in meeting domestic energy needs and generating income has also brought down violence in their community.
Another source of hope is the development of Southern country partnerships that can share experiences relevant to Haiti’s conditions and build supportive networks for skills and knowledge building. Haitian journalists spoke of the need to develop links with African and Asian countries that would enable them to draw from developing country experiences that are relevant to their needs.