20208: DeGraff: Farmer's Open Letter to Secretary Powell: Need for Medical Neutrality in Haiti (fwd)

[Bob Corbett <corbetre@webster.edu>]

From: Michel DeGraff <degraff@MIT.EDU>

In recent weeks, a long-simmering conflict in Haiti has erupted to trouble
an already troubled world. As an American doctor working in Haiti, I am
writing to air my concerns  about the conditions under which health care
delivery must now take place.  For weeks, the country's only large public
teaching hospital has been paralyzed by violence and dissent. For years,
economic pressure largely, though not wholly, resulting from an
international aid embargo, has left almost nothing to invest in the care
of the destitute sick. For a sense of how meager the health investments
have been, consider the experience of an American doctor who commutes
between a Harvard teaching hospital and a squatter settlement in rural
Haiti. In 2003 the budget of the entire Republic of Haiti, population 8
million, was less than $300 million. The 2003 budget of a single Harvard
teaching hospital-- and there are two dozen Harvard teaching hospitals--
was pegged at $1.3 billion.

A longstanding dearth of funds for health care and other services coupled
with a rising tide of violence and disarray have led to a terrible
humanitarian crisis in Haiti, a crisis with deep roots. The past two weeks
have seen an almost complete shutdown of services in much of
Port-au-Prince. A report from the Pan American Health Organization, worth
citing at length, offers small reason for optimism:

 "The intensifying socio-political crisis in Haiti is having a negative
impact on the health of the Haitian population. Haiti has the highest
infant and maternal mortality, the worst malnutrition and the worst AIDS
situation in the Americas. The general mortality rate was 1057 per 100,000
population during the 1995-2000 period, also the highest in the Americas.
A quarter of the children suffer from chronic malnutrition, 3 to 6% of
acute malnutrition. About 15% of newborns have a low birth weight. Acute
respiratory infections and diarrheas cause half of the deaths in children
under 5 years of age. There are complications in a quarter of the
deliveries. The coverage of services is very low: 40% of the population
has no real access to basic health care, 76% of deliveries are made by
non-qualified personnel, more than half of the population has no access to
drugs, and only half of the children are vaccinated."

The report, filed a few days ago, goes on to signal "disregard for the
health institutions' neutrality and immunity. Several hospitals were the
target of violence. Patients were assaulted in some institutions and the
staff providing care is worried about exercising their duties safely. In
some health institutions, the staff does not report for work on the day of
demonstrations. Some of the patients in need of emergency care do not go
to hospitals anymore for fear of violence. The Port-au-Prince University
Hospital, one of the main hospitals in the country, has been almost at a
standstill for weeks, for lack of personnel."

The report note that "insecurity is highest in Artibonite and Central"
departments. Our own medical and public-health efforts are based in the
Central Department, where I have worked and lived for over 20 years. Just
over a week ago, two of our medical vehicles were commandeered by the
heavily armed men who today call themselves Haiti's "military leaders."


Medical education is also at a standstill. The Central Department boasts
no home-grown doctors; our own medical staff is from Port-au-Prince or
Cuba. There are fewer than 2000 doctors in the entire country and more
than 90% of them are based in the capital city of Port-au-Prince. Even
there, the urban poor have little access to modern health care. Haiti
produces doctors, but its history of repeated coups and brutal
dictatorships makes it next to impossible for the country to keep them.
Historians report that "In the decade following the [1957] ascent of Dr.
Francois Duvalier to powerE280A6  264 physicians graduated from the
state medical school, and all but 3 left the country."

Few would disagree, then, that the training of doctors and the delivery of
services are urgent priorities in the Western world's most impoverished
nation. If we can agree on these two points, it's of concern that two
important new health care institutions are today under siege or worse.

The University of Tabarre recently inaugurated Haiti's newest medical
school. Unlike other faculties in Haiti, this one recruited medical
students from poor families residing in each of Haiti's nine departments.

Talented young people from rural Haiti have previously found it nearly
impossible to make their way to medical school, but this institution seeks
out young men and women from poor families, trainees who declare a
commitment to returning to communities throughout Haiti's villages and
towns and slums. Both creating much-needed opportunities and answering a
desperate need, this new facility was dedicated in December 2003. Taiwan's
ambassador to Haiti then spoke of Taiwanese providing the funding for the
"hardware" and the Cuban faculty as providing the "software."

The teaching hospital of the Universite of Tabarre, shared with Haiti's
state university and its leading private medical schools, opened on
February 6 in the Delmas area of Port-au-Prince. Less than 24 hours after
the ribbon was cut, babies were being delivered in the safety of a modern
medical facility-- a rarity in Haiti, where one in every 16 women die in
childbirth.

But good news rarely lasts long in Haiti: a few days ago Haiti's
newest medical school was turned into a military base for U.S. and
other troops, but not until after it was pillaged and stripped of its
teaching materials and books. What has become of its faculty, in
large part Cuban public health specialists but also counting Haitian,
U.S., and European teachers?

More to the point, what will become of its 247 medical students? What will
happen to the dean of that school, Yves Polynice, a Haitian surgeon
trained in Germany and now forced to flee Haiti at a time when trained
medical educators, to say nothing of surgeons, are in such short supply?
In summary, what will become of the only medical school in Haiti whose top
priority is developing a cadre of physicians in the service of Haiti's
poor and vulnerable?

Over the past week, medical staff working at Delmas, Tabarre and elsewhere
have been threatened, as have Ministry of Health personnel. "Political
reasons" are cited as the motive for threats to their lives and the
possible destruction of their newly-founded institutions: for in the
hemisphere's most polarized country, both the medical school and the
teaching hospital are projects of the Aristide Foundation for Democracy.
When yesterday violence erupted in Port-au-Prince, there was almost
nowhere to take the wounded.


Whether the presence of foreign troops will achieve a return to order
in Haiti is not yet known. But at the very least, the international
forces under U.S. direction should make these facilities safe for
patients and staff. The E2809CrebelsE2809D who present themselves as
the revived Haitian Army include men who intimidate doctors and
nurses, deny medical care to the wounded, pillage facilities, steal
scarce supplies and equipment, and are eager, for political reasons,
to wipe out any and all legacies of the Aristide Foundation and the
Lavalas Party. The desperateness of Haiti's situation transcends
politics. Hospitals should remain open to all those who need care,
and no training facilities should be closed. In the turmoil of rival
factions and muddled loyalties that is Haiti now, the need for
medical services provides an indisputable E2809Carea of moral
clarity.

Paul Farmer, M.D., Ph.D.

Medical Director
Clinique Bon Sauveur
and
Professor
Harvard Medical School