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By Rupa Chinai Malnutrition and maternal and infant mortality rates are extremely high in Haiti. Chronic malnutrition is seen as the biggest hurdle in raising socio-economic indicators in the country
If conditions of health are anything to go by in judging the progress of a people, Haiti sits at the bottom of the barrel. It represents one of the most tragic case studies within the developing world of how nations lose the right to determine their sovereignty and ensure access to health when they lose their right to local food self-sufficiency. A week spent in rural and urban Haiti in early-June studying the issue of access to health revealed the absence of political will, both nationally and internationally, to address the vital question of how Haiti can begin to rebuild its basic health infrastructure, create a knowledge and skills base within its manpower, and produce real nourishing food that will sustain the health and economic survival of 80% of its poor. An examination of health services at a public hospital in the rural ‘department’, or district, of Jacmel offered an insight into the ground realities. In the women’s ward of the hospital, nuns (the only caregivers seen) watch in despair as patients writhe in pain, slip in and out of a coma, or lie bleeding profusely. The hospital does not provide free lifesaving drugs, and the women are too poor to buy them. When questioned, Haiti’s minister of health says that it offers free obstetric care at its labour centres and that women can approach health promoters for free drugs. Why then are these not housed within the only public hospital in the department? No clear answer. According to Haitian NGOs, government agencies do not provide lifesaving drugs. While the WHO does offer some general drugs, the bulk of Haiti’s donors focus exclusively on AIDS drugs.
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 in from the periphery have to travel up to eight hours by boat to reach Jacmel. The ticket costs US$ 8; the average Haitian earns $ 50 a month. Even when patients do manage to reach the Jacmel hospital there is no guarantee that services will be available. The last surgeon who worked at the hospital was in 2004. There has been no anaesthetist at the hospital for over a month, and no obstetrician since 2006. Doctors are not paid and no one is willing to work here. Haiti’s medical professionals have fled and the country now depends on Cuba for trained doctors. Apart from no salary, doctors lack equipment or any form of support. The country has barely one doctor per 10,000 people. Haiti and Cuba have a 10-year cooperation agreement for development of Haiti’s medical professionals. Haitian doctors trained in Cuba have to give 10 years to government service; in reality, up to half refuse to come back or move to work in the US.
For three weeks running the hospital has been without electricity following the breakdown of the generator and absence of any back-up. The town’s gasoline-based electricity supply has deteriorated. Consumers are unable to pay for the rise in fuel costs and so supply is restricted to barely two hours a day -- that too if they are lucky. There is only one ambulance attached to the Jacmel hospital. It’s supposed to cater to the entire district. “Human resources and everything else are kept in Port-au-Prince,” admits Deslouches Gaston, Jacmel department’s director of health services. Patients cannot, however, go directly to the capital for treatment. Though they may be very ill, they lose two days travelling to the Jacmel hospital for a referral. Haiti’s elite seek services in the neighbouring Dominican Republic or in the US. The rest, like the patients in the women’s ward at Jacmel hospital, have no option but to quietly lie down and die. Voodoo, a traditional healing practice and religion brought to Haiti by the first African slaves, is a major force in the lives of the people here. But although it is given official recognition it has not received much support, complains Celestin Saummervil, a voodoo priest. According to him, voodoo and the use of traditional medicine play an important role in curing certain health problems and it should be tried before seeking modern medicine. Saummervil explains that traditional healers receive training from professional doctors and also refer patients to hospitals. But the collaboration is only one-way, as the Christian church opposes voodoo. While voodoo can use black magic to cause harm, most priests believe that it must be used to protect and help people. “The situation faced by rural patients is bad 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,” says Saummervil. Haiti’s main health problems relate to high maternal and infant mortality, tuberculosis, AIDS, malaria, infectious diseases, high blood pressure and dental problems, says Dr Gaston. Patients are late in seeking healthcare, for, apart from the issue of access, only those with economic power can make timely decisions to go to a health facility. Haiti’s high maternal mortality rate -- 630 per 100,000 -- is mainly on account of anaemia which causes pregnancy-related complications such as eclampsia and haemorrhage, and low-birth-weight babies. Haiti’s infant mortality rate is 87 per 1,000 for children under five years, and 53 per 1,000 for those under one year, says Unicef’s Haiti office. The main cause of death is pneumonia and diarrhoea. “In the regional context it is a very bad situation,” says a Unicef spokesperson. “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.” Unicef points to studies that show that 23% of Haiti’s children suffer chronic malnutrition, while 9% are acutely malnourished. In some areas of Haiti, acute malnutrition has reached 10% -- a level that, by international standards, warrants pulling of the “emergency trigger” says Unicef. Chronic malnourishment is underlying and widespread in Haiti. It affects children’s long-term development. By age two, its impact on the child cannot be reversed. Acute malnutrition is recognised by bow legs and swollen, thin limbs. Both arise from lack of nutritious food -- basic staples and micronutrients. Young women need access to nutritious food long before they become pregnant; interventions during pregnancy are too late. International studies point to the link between low-birth-weight babies and heart disease in adulthood. The Unicef spokesperson points out that 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. Unicef’s efforts towards helping children in Haiti revolve around vaccinations, conducting surveys, and preparations to promote “therapeutic food”. This is a ready-to-eat food supplement made from milk, peanuts and added chemical micronutrients. “It is seen as 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 clarifies. But health agencies working in Haiti, including Unicef, are clear that drug and food therapies do not address the key issue -- 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 1950s, Haiti used to feed the other Caribbean islands. We have not given importance to developing its potential over the last many years,” said an aid worker. Apart from the Cubans, European and Canadian aid agencies seem to be the only ones making a useful contribution to the long-term development of Haiti’s health services. They focus on maternal and child health and are putting money into the development of primary healthcare, salaries, training of community health workers and local midwives, and the development of material for preventive education. This effort however is restricted to five ‘communes’; it does not cover Jacmel. Individual philanthropists in the US do support Haiti’s orphanages but the majority of the 200,000 children receive no organised support, says Unicef. According to Unicef, the bulk of aid money coming into Haiti focuses on HIV/AIDS. At the forefront is the US, which is Haiti’s biggest donor and a major supplier of pharmaceuticals. Its main concern, however, is not with the needs of the local people but how aid money can be ploughed back to US industries that have invested heavily in HIV/AIDS drugs and diagnostics. The Bush government, for instance, initiated the President’s Emergency Plan for AIDS Relief (Pepfar) -- a major programme to provide antiretroviral (ARV) drugs and diagnostic kits for the 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 drugs. It also needs highly trained technicians who can ensure accurate results. Neither is available in Haiti. And while ARV drugs may help prolong life, they do not offer a cure. There is no evidence of how it helps malnourished populations with a heavy burden of disease who cannot survive on tablets alone. And the US provides no guarantee that the provision of these expensive ARV drugs will continue indefinitely for patients already on the regimen. “Haiti’s family planning programme also started like this,” says Marie Mercy Zevllos, director of the Hope Centre that provides AIDS counselling. “Initially, we received all the support -- technical and financial. But then when the government changed in the US, the programme ended. The current approach is good for the pharma industry in the US; it’s helping us to help themselves.” The obsession to provide Haiti with AIDS drugs has not extended to other lifesaving drugs for the vast majority of the population. Drugs for AIDS-related opportunistic infections, such as TB and diarrhoea, are also scarce. Even as the rising disease graph in Haiti points to a host of health problems, and a health system that is in a shambles, the government and US-sponsored AIDS lobby claim success in bringing down HIV/AIDS in Haiti! What’s missing in the AIDS-obsessed discourse is the vital role of locally produced nutritious food, clean water and sanitation, and the difference these things would make to diseases across the board. Short on trained human resources and subjected to constant political instability, the Haitian government has never been able to go beyond emergency mode. In such a situation, hope lies in the emergence of community-based organisations that are beginning to take charge by understanding the factors that sustain their health and their environment. One such initiative was evident in Marigot where local youth organisations are planting trees to help hold the topsoil, rejuvenate soil fertility and ultimately lead to the return of local food self-sufficiency. In Port-au-Prince, a slum community revealed how technical and financial support from India, Brazil and South Africa was helping them run a pilot project for the creation of fuel briquettes from waste. This initiative is meeting domestic energy needs, generating income and leading to a drop in violence within the community. Another source of hope is the development of Southern country partnerships that are able to share experiences relevant to local 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 relevant developing country experiences. Also read The real food crisis in Haiti (Rupa Chinai is an independent journalist based in Mumbai. Her trip to Haiti was supported by Media 21, a global network of journalists, and Infosud, a Swiss news agency) InfoChange News & Features, July 2008
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