21367: Belani: Paul Farmer on Political Violence & Public Health in Haiti (fwd)

[Bob Corbett <corbetre@webster.edu>]

From: Aarthi Kumar Belani <aarthib@stanfordalumni.org>


 New England Journal of Medicine
 350(15):1483-1486
 April 8, 2004

 Political Violence and Public Health in Haiti
 Paul Farmer, M.D., Ph.D.

 In 1991, a violent military coup unseated Haiti's first
 democratically elected government. An estimated 5000 people died,
 and hundreds of thousands more were displaced during the three years
 when military and paramilitary groups ruled the country. It was my
 privilege and responsibility to help provide basic medical services
 in central Haiti (see map and figure) during those years. After
 constitutional rule was restored in 1994, it was possible to assess the
 effects of those events on our medical and public health efforts in the
 central plateau. We termed these years the "lost years," since many of
 our efforts required a modicum of order and a functioning public health
 system in order to bear fruit.

 In the years since 1994, the nongovernmental organization Partners
 in Health has been able to forge strong public-private partnerships
 throughout central Haiti. During the past three years, for example,
 we have scaled up an integrated AIDS prevention and care project in
 this region. With support from the Global Fund to Fight AIDS,
 Tuberculosis, and Malaria, about 1000 patients with advanced human
 immunodeficiency virus disease are currently receiving supervised,
 community-based care and treatment. Working in conjunction with
 underfunded public health clinics, we were witness to the
 reinvigoration of primary health care in many of the major towns in
 central Haiti. [1,2]

 But recently, a long-simmering conflict in Haiti has erupted and
 threatens to reverse these important gains. There is no denying that
 Haiti's 33rd coup d'etat brings an end to constitutional rule. As
 physicians and health workers, we must note that Haiti's only large
 public teaching hospital has been paralyzed by violence and dissent.
 For years, economic pressure resulting largely, though not wholly,
 from an international embargo on loans and aid 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 central Haiti. Revenues for
 the entire Republic of Haiti, population 8.3 million, were less than
 $300 million in 2003. During the same year, revenues for a single
 Harvard teaching hospital - and there are 17 Harvard teaching
 hospitals - were pegged at $1.3 billion. Most Haitians, the poor
 majority, simply go without modern health care even in the absence
 of political turmoil.

 But this turmoil adds a special burden to both patients and
 providers. A long-standing dearth of funds for health care and other
 services, coupled with a rising tide of violence and mayhem, has led
 to the worst humanitarian crisis the region has known in decades.
 The past two months have seen a shutdown of services in much of
 Port-au-Prince. A recent report from the Pan American Health
 Organization (PAHO) offers little reason for optimism in the longer
 term:

 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. [3]

 The report goes on to signal "disregard for the health institutions'
 neutrality and immunity" and notes that "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."

 PAHO also reports that "insecurity is highest in [the] Artibonite
 and Central" departments, or regions. Our own efforts are based in
 the Central Department, where I have worked and lived for more than
 20 years. We know this insecurity well. Recently, three of our
 medical vehicles were commandeered - two in Lascahobas and one in
 Thomonde - by the heavily armed men who have once again assumed
 command as Haiti's military leaders. Last May, the same men had
 stolen another ambulance and held five members of our medical staff
 hostage for several hours in the town of Péligre. They had already
 killed two night watchmen, both patients of ours, at the country's
 only large hydroelectric plant.

 These vehicles are crucial to the functioning of our hospitals and
 clinics, since trucking of medicines and other supplies to
 devastated central Haiti is the only means by which we can provide
 care effectively. Transport of personnel is also essential: the
 Central Department boasts no home-grown doctors, and our own medical
 staff is from Port-au-Prince or Cuba. There are fewer than 2000
 doctors in the entire country, and most of them are based in
 Port-au-Prince, where less than a quarter of Haiti's people live.
 Haiti produces doctors, but its history of repeated coups and brutal
 dictatorships makes it next to impossible for the country to keep
 them. This problem is not new. Historians report that "in the decade
 following the 1957 ascent of Dr. François ["Papa Doc"] Duvalier to
 power . . . 264 physicians graduated from the state medical school,
 and all but 3 left the country." [4]

 In the past few years, however, three new medical schools have been
 established in this impoverished nation. One of these institutions,
 the University of Tabarre, has recruited medical students from poor
 families residing in all nine of Haiti's departments. Talented young
 people from rural Haiti had previously found it nearly impossible to
 make their way to medical school, but this institution specifically
 seeks young trainees who are willing to make a commitment to
 returning to their home communities. Both creating essential
 opportunities and answering a desperate need, a new campus for this
 school was dedicated in December 2003.

 Against all odds, even more progress was made. The teaching hospital
 of the University of Tabarre, to be 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 maternal
 mortality rates are appalling. Even the low-end estimates (523 per
 100,000 live births) are the worst in the hemisphere, and one
 community-based survey conducted in the mid-1980s pegged the rate at
 1400 per 100,000 live births.

 But good news rarely lasts long in Haiti: in early March, Haiti's
 newest medical school was turned into a military base for U.S. and
 other foreign troops. What will become of its faculty, composed in
 large part of Cuban public health specialists but also including
 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, a Haitian surgeon who was trained in Germany? In short,
 what will become of the only medical school in Haiti whose top
 priority is the development of a cadre of physicians to serve the
 nation's poorest and most vulnerable people?

 Whether the presence of foreign troops will achieve a return to
 order in Haiti is not yet known. But so far the rebels who consider
 themselves 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 Aristide, who
 founded the medical school and the teaching hospital. One would
 think that the desperateness of Haiti's situation would transcend
 politics, that hospitals should remain open to all those who need
 care, and that no training facilities should be closed. In the
 turmoil of rival factions and muddled loyalties that is Haiti now,
 the need for medical services should stand as an indisputable area
 of moral clarity.

 Clearly, Haiti needs emergency assistance. Haiti, the oldest
 neighbor of the United States, is far and away the Western world's
 most impoverished nation. Yet official aid to Haiti has not been
 very substantial during the past decade. At the height of our
 involvement, for example, the United States was giving Haiti, per
 capita, 1/10 of what it was distributing in Kosovo. Little of this
 aid passed through elected officials and government agencies. Over
 the past three years, almost all of the money went to
 nongovernmental organizations, and some of it to the anti-Aristide
 forces. [5] The funding cuts and diversion to the opposition
 precluded efforts to rebuild schools, health care infrastructure,
 ports, roads, and airports.

 Today, we are reassured that experts in "complex humanitarian
 disasters" will henceforth manage aid to Haiti. But tardy and
 disorganized interventions will not undo a decade of misguided aid
 policies. Nor are piecemeal approaches focused on nongovernmental
 organizations likely to improve the basic health of the Haitian
 people. Robust public health requires a strong ministry of health,
 which should itself derive legitimacy from an elected government.
 The fates of a few thousand people living with AIDS in central Haiti
 may be determined by groups like ours, with or without our
 ambulances and other vehicles. We and our Haitian coworkers are
 proud of our work here. But millions of Haitians need basic health
 services, and these services will not be available without a
 stronger public health infrastructure, improved medical education,
 and an end to the politicization of aid that stands as one of the
 most shameful chapters in international health.

 Source Information
 From Clinique Bon Sauveur, Cange, Haiti; Harvard Medical School,
 Boston; and the Division of Social Medicine and Health Inequalities,
 Brigham and Women's Hospital, Boston.

 Map: Haiti

 Figure: Crowds of sick patients wait overnight for medical
 assistance in Haiti's Central Department. Photograph courtesy of
 David Walton, Partners in Health, 2003.

 References
 1.  Mukherjee JS. HIV-1 care in resource-poor settings: a view from
 Haiti. Lancet 2003;362:994-995.
 2.  Mukherjee JS, Farmer PE, Niyizonkiza D, et al. Tackling HIV in
 resource poor countries. BMJ 2003;237:1104-1106.
 3.  Pan American Health Organization. The Haiti crisis: health
 risks. (Accessed March 19, 2004, at:
 http://www.paho.org/English/DD/PED/HaitiHealthImpact.htm
 <http://www.paho.org/English/DD/PED/HaitiHealthImpact.htm> .)
 4.  Diederich B, Burt A. Papa Doc et les Tontons Macoutes. Henri
 Drevet, trans. Port-au-Prince, Haiti: Imprimerie Henri Deschamps,
 1986:366.
 5.  Farmer P, Fawzi MC, Nevil P. Unjust embargo of aid for Haiti.
 Lancet 2003;361:420-423.