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Haiti's forgotten emergency

By Patralekha Chatterjee, The Lancet, UK

Haiti's new Prime Minister has stated that improving health care on the island will be one of her top priorities. But repairing the health system in a country plagued by turmoil, natural disasters, and a serious HIV/AIDS epidemic is not going to be an easy task.

Haiti—a spectacularly beautiful Caribbean island of mountains and gleaming sandy beaches—should have been a tourist paradise. Instead, it makes news as one of the world's most unstable countries.

Images of angry people burning tyres and blocking national highways and city streets in Port-au-Prince—the Haitian capital—flashed across television screens in April this year. The protests were against the staggering rise in the cost of staple foods.

In mid July, once again, a peaceful demonstration had turned violent in Haiti's capital city. Faced with skyrocketing food prices, poor people in Haiti have been forced to eat "mud cookies" made up of salt, vegetable oil, and dirt to stave off their hunger, several news reports noted over the past few months.

Aside from these telegenic images of conflict, however, another crisis has become equally grave. The lack of access to health care for most of the population, especially in rural Haiti, risks becoming the forgotten emergency in this nation of almost 9 million people, which is ranked 146th of 177 countries in the UN's latest Human Development Index.

Initiatives to improve the situation are derailed by the constant political upheavals and bloodshed on the island. Haiti's high population density and its decrepit infrastructure mean that it is also vulnerable to devastation from natural disasters such as floods, mudslides, and hurricanes.

The latest round of turbulence in April began when Haiti's hunger pains erupted into angry violence, leading to the closure of businesses and schools. The week of deadly protests against the rising cost of food forced Haitian Prime Minister Jacques Edouard Alexis to resign.

After 4 months of political deadlock that left Haiti unable to sign foreign aid deals, the country finally has a new Prime Minister, 61-year-old Michèle Pierre-Louis. Pierre-Louis—the second woman to become Prime Minister of Haiti—says her top priorities will be food security, employment, infrastructure upgrades, and health care. But "It's going to be very difficult. To govern this country is not going to be easy", she acknowledged in her first press conference in August.

The protracted political uncertainty and the resultant lull in decision making in recent months has exacerbated an already precarious state of affairs. Haiti has weak state institutions; a lack of doctors, health workers, and medicine supplies; poor roads; and a fragile infrastructure. This situation confronts most Haitians who are poor and live under an increasingly inequitable system.

Some 4% of Haiti's population have 66% of the nation's wealth, whereas 10% have practically nothing. 47% of Haitians lack access to basic health care and 50% lack access to basic drugs. Meanwhile, the cost of health care is going up. A medical consultation that cost 25 Haitian Gourdes (HTG) in the late 1980s now costs 1200 HTG (US$1=38 HTG)—48 times more, according to the Health in the Americas report released in 2007 by the Pan American Health Organization (PAHO).

Vast disparities also exist between urban and rural areas, and between regions: fewer than 40% of the population have access to basic health services in certain regions such as the west, north, and northeast. The absence of a public-health system might explain why 80% of Haitians turn to traditional healers.

Health projects have an uneven geographical spread. International agencies say that violence and lawlessness prevent them from reaching the most deprived and vulnerable people.

Years of political instability have left hospitals and the health system in a shambolic state (panel 1). "You cannot undo 20 years of disorder overnight", Robert Auguste, Haiti's minister of population and health, told The Lancet. "But since the past 2 years, we have begun rebuilding the health system. We have also tried to figure out why the Haitian populace cannot access public services. We have made a start. In Jacmel, for instance, we have started construction and are repairing health-care centres. After that, we would look at the issue of personnel."

Panel 1: The daily struggle in a hospital in Haiti

A visit to the L'Hôpital Saint-Michel in Jacmel—a picturesque coastal town in southern Haiti, which is about a 3 h drive from Port-au-Prince—reveals the daily struggle of health workers. Power outage is a chronic problem throughout the country, but the situation at the hospital degenerated into a full-blown crisis in May and June this year, when the back-up generator broke down. "We have almost nothing here. Hardly any staff or material. Right now, there is not even any gauze. I bring gauze and a flash torch from home since there is no electricity. If we have to use a suture in the night, we do it by candle or torch light", Marie Edith Henry, a volunteer nurse at the hospital, told The Lancet.

A few yards away from where Henry sat, lay Desiree St Anne, a 37-year-old woman, who was 6 months pregnant. She had had a previous miscarriage, was severely anaemic, and was likely to require a C-section at the time of her delivery because of placenta previa, Henry pointed out. But surgeries had been discontinued in the hospital due to the power outage.

In another part of the hospital, a young man sat quietly in the dark, working on a battery-operated laptop. Returnio Tgalite counsels people in the hospital's voluntary counselling and testing centre for HIV/AIDS. A box of condoms lay in the corner of the tiny cubicle which serves as Tgalite's office. "A lot more needs to be done to sensitise people, especially the young. The information gap about HIV/AIDS between towns and rural areas is still incredibly wide", he said.

Rising oil prices have worsened the power situation. "The hospital cannot afford to pay the price of the fuel…we need to find a way to lower the fuel expenses with help from partner agencies", said Yves Gaston Deslouches, health director of Haiti's southeast region.

The situation is getting better. "The health ministry gave the hospital a new 20 kW generator. The UN Stablization Mission in Haiti has also offered us a 175 kW generator. The government has agreed, in principle, to pay for the installation. A new anaesthetist has joined the hospital. But we are still desperately short of specialists. The hospital cannot undertake many interventions because of the lack of urologists, psychiatrists, and so on. The operating theatre also needs to be repaired", said Deslouches.

The delay in debt relief

A key factor affecting Haiti's national expenditure on public health is its external debt. The country's legacy of debt can be traced back to the immediate aftermath of its independence from France in 1804. Haitians say that in 1825, France, with warships at the ready, demanded that Haiti "compensate" France for its loss of a slave colony. In exchange for French recognition of Haiti as a sovereign republic, France demanded payment of 150 million francs, which is around $21 billion today.

Currently, Haiti is saddled with a debt of $1·3 billion. More than 40% of this debt was incurred during the dictatorship of François Duvalier (1957–86). Haiti has only recently qualified for debt relief under the World Bank and International Monetary Fund's Heavily Indebted Poor Country Initiative, established in 1996. But it will not actually receive debt relief until it has met a series of conditions, including economic policy reforms with debatable merits, say several activists and independent think-tanks that have advocated for immediate debt cancellation. These groups also want an interim moratorium on debt service payments for Haiti (and all poor countries) to help them cope with the mounting food crisis and to free up desperately needed resources for socioeconomic development.

As it is, 72% of the country's total health budget comes from external sources, Auguste said. Without external aid, the country's precarious situation would be worse. Government officials, however, point to the need for greater coordination between the activities of different international agencies that operate in the island.

Women and children worse off

Women and children bear the brunt of Haiti's health crisis. Haiti's maternal mortality ratio (MMR) is 630 per 100 000 livebirths, according to UNICEF (panel 2). This ratio has a direct effect on child survival and health—Haiti also has the highest rates of mortality for infants and children younger than 5 years in the Americas.

Panel 2: Summary of key health indicators in Haiti

•54% of population live on less than US$1 a day

•25% of births are institutional deliveries

•26% of births have a skilled attendant at delivery

•The maternal mortality ratio is 630 per 100 000 livebirths

•The under-5 mortality rate is 80 per 1000 livebirths

•The infant mortality rate is 60 per 1000 livebirths

•14% of the rural population use adequate sanitation facilities

•57% of the urban population use adequate sanitation facilities

•3·8% of adults (15–49 years) live with HIV/AIDS

Source: UNICEF. http://www.unicef.org/infobyco...

Yves Gaston Deslouches, health director of Haiti's southeast region, explained why so many Haitian women die during pregnancy and childbirth. "There is virtually no public transport in many parts of the island. A pregnant woman has to travel 6–7 h by boat from a remote, rural, mountainous area, paying almost $10 for one journey to get to a place from where she can access some form of transport. For many, whose monthly income is barely $50, this is a huge cost. When she gets to a health centre or hospital, there are other costs because these institutions are ill-equipped. For a woman in a remote, rural area who needs a C-section and who has to come to a hospital like St Michel in Jacmel, it is a long arduous journey." Another complication: a patient cannot go directly to the hospitals in Port-au-Prince, which has better infrastructure. "You have to be referred", he said.

Many pregnant women die en route because of the many delays in accessing health facilities. Those that die after childbirth leave their newborn with an uncertain future. "The state of the children in the country is related to its maternal mortality rate, comparable to some of the worst MMRs in Africa. Our efforts have been towards programme convergence between maternal mortality and infant mortality because we have seen that if a mother dies, the child is unlikely to make it to his or her first birthday", said Teresa De la Torre, the chief of health and nutrition at UNICEF-Haiti.

Nutrition crisis

The spiralling food prices are also putting children at risk. 23% of children in Haiti have chronic malnutrition and 9% have acute malnutrition, according to official statistics. These figures worry international agencies and the government alike. "Internationally, if you have a 10% acute malnutrition in a population, that is an emergency. In Haiti, there is 9% acute malnutrition [in children], according to a national survey done 2 years ago. But we have reason to believe that there are areas where the acute malnutrition rate is above 10% and chronic malnutrition is the underlying big issue", De la Torre told The Lancet. "These are very big concerns because nutrition affects the development of the child and the ability of the child to realise his or her potential."

The roots of Haiti's nutrition crisis go back to the decline in agricultural production, which happened over a decade ago. Haiti was almost self-sufficient in rice production, according to many analysts within and outside the country. But in 1995, when international institutions pressured Haiti to cut import tariffs on rice from 50% to 3%, cheap subsidised rice from the USA started coming into the country. Urban consumers benefited for a while from the low-cost imports, but they caused national rice production to plummet. Today, Haiti imports 80% of the rice it consumes—just as world prices have doubled.

The rising costs of staple foods in Haiti is putting the country's children at risk of malnutrition

Getty Images

The plummeting agricultural production has had a two-fold effect. "First, the nutritional status of children has deteriorated; recent surveys indicate an alarming increase in malnutrition in urban areas. Second, the widening of the trade deficit due to a rise in imports, notably food products, has been largely responsible for the devaluation of the country's currency and the rise in cost of living", PAHO's Health in Americas report pointed out.

Flight of white coats

Haiti's health system is further weakened by its health-worker crisis. Like in many parts of Africa, Haiti is facing an unprecedented exodus of its health-care professionals. Apart from obvious financial benefits in moving to other countries, kidnappings have also played a part in driving health professionals away.

"Out of the 78 doctors in my batch, only 20 remain in the country", laments Auguste. "Nearly 30% of health workers and medical professionals left the country in the past 3 years to go to the USA or Canada", Gabriel Thimothe, Haiti's director general of health services told The Lancet. However, he says: "We are implementing a medium-term plan to train doctors, nurses, lab technicians, and others with help from Canada."

In the meantime, Cuba is trying to plug the gap left by the exodus. It has been training many Haitian doctors and sending its own doctors for short periods to work in hospitals in the impoverished island.

Flickers of hope

Despite its troubled history, Haiti offers examples of success and inspiration. It is among the few countries in the developing world which have made demonstrable progress over the past 3 years in reducing their child death rate. The mortality rate for children younger than 5 years dropped from 152 per 1000 livebirths to 80 per 1000 livebirths between 1990 and 2006. Haiti's infant mortality rate has also declined from 105 per 1000 livebirths in 1990 to 60 per 1000 livebirths in 2006, according to UNICEF's State of the World's Children 2008 report. The figures are still unacceptably high but they point to progress.

Haiti has boosted access to antiretroviral drugs in the country over the past 2 years

Corbis

"Between 2000 and 2006, most child-health indicators have shown some improvement. But there has been little improvement in maternal health. The gains in child survival and health are due to a combination of initiatives—scaling-up of mass immunisation, expansion of paediatric HIV/AIDS treatment, and perhaps the fact that in recent years, investments from the international donor community have been considerable", said De la Torre.

Thanks to supplies, medical equipment, and technical assistance from international agencies, such as UNICEF, routine immunisation coverage has improved substantially in recent years. Last year, health officials in Haiti rolled out the largest mass vaccination campaign in the country's history, which aimed to inoculate every child against rubella, poliomyelitis, and other common infectious diseases.

Haiti has also won plaudits for a decline in HIV prevalence in its adult population, especially in the rural areas. 2·2% of the adult population in Haiti live with HIV/AIDS, according to the latest national demographics. Antiretroviral (ARV) therapy has been available in the country since 2003, chiefly through centres run by two organisations: the Haitian group for the Study of Kaposi's Sarcoma and Opportunistic Infections and Zanmi Lasante (Haitian Creole for Partners in Health). But access to this treatment has improved in recent years.

"2 years ago, we had only two institutions which administered ARV. Now, we have 48. ARV is being given to 15 000 people, up from 200 in 2002 because of substantial financing from external agencies", Thimothe told The Lancet. "Political will, a strong partnership between the public and private sector, including civil society, innovative interventions among young people to promote condom use, and initiatives with key constituencies: female sex workers, youth, and rural populations…are key factors which have contributed in bringing down the HIV/AIDS prevalence in Haiti." Assistance from the Global Fund to fight AIDS, Tuberculosis and Malaria and the US President's Emergency Plan for AIDS Relief has helped Haiti to achieve its success in tackling HIV/AIDS, he added.

Meanwhile, the nutrition crisis in the island is climbing up the policy agenda. According to De la Torre, UNICEF and its partner agencies are currently drawing up a contingency plan to deal with nutritional emergencies in case of worsening of food prices and natural disasters.

"We are mapping who is doing what and where. In Haiti, we do not have many NGOs [non-governmental organisations] working in nutrition, or many with the capacity to do nutritional surveys or community-based treatment of acute malnutrition. We are training people to build [workforce] capacity and to equip field workers with tools, so that whoever goes out is able to assess and compare the situation with what is happening elsewhere. We are also working to make sure that there are enough supplies—basic drugs and therapeutic foods such as plumpy nuts [peanut butter fortified with milk and vitamins]", she noted.

There is also a growing realisation that health-care services have to be made more accessible at the community level, given the country's poor infrastructure. It is early days, but the process of decentralising the health system has begun. 11 Community Health Units in five regions were up and running by 2006. Haiti's health officials are also paying greater attention to the health-worker crisis crippling the island. "We have raised doctors' salaries. We are also training more medical professionals. By the end of this year, we will have 500 more medical graduates in addition to those being trained in Cuba. I am optimistic that things will improve", said Thimothe.

Indeed, amid the masses of bleak data, these are the flickers of hope. With a new Prime Minister in place, Haiti has a window of opportunity to achieve political stability and fulfil Thimothe's optimistic forecast.

Patralekha Chatterjee's trip to Haiti was supported by Media 21, a global journalism network developed by InfoSud—a Geneva-based press agency and a nonprofit association.

ORIGINAL Article (The Lancet website - requires free registration)

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