IHSJ Issue: Haiti

1. History and Background
2. Health in Haiti
3. Advocating for Health as a Public Good and Human Right
4. Water
5. Food Security
6. Current State of Affairs
7. Recent Advocacy

History and Background

For those of us committed to justice in Haiti, the poorest country in the Western Hemisphere and one of the poorest and hungriest countries in the world, many questions arise: Why is the situation in Haiti so bad? Is it a “failed state”? It is impossible to understand present-day Haiti without understanding the country’s past. At the turn of the nineteenth-century Haiti was the property of France, a colony that generated more profit than any other French holding [1]. During this period Haiti would more accurately be described as a large slave plantation. The island’s indigenous people had long been dead, killed by Columbus and the first wave of European explorers, and finished off by the brutal work conditions of sugar plantations [2]. From 1791 through 1803, the island’s slaves and their descendants successfully orchestrated a strategically brilliant revolution that defeated Napoleon’s army. On January 1, 1804, after a struggle that claimed the lives of more than 100,000 slaves, the Republic of Haiti became the first independent Black republic and the first modern nation born of a slave revolution  [3]. The protracted struggle destroyed much of the country’s colonial infrastructure, including its hospitals [4]. Access to clean water, adequate sanitation, health care and stable food supplies were all virtually eliminated [5]. The international community’s response to Haiti’s rebellion set in motion a series of events that have kept the nation impoverished through to today.

Slavery--with its oppressive twin, colonialism--built many of the powerful empires of Europe. Slavery was still part of the economic engine of the United States, and so the first successful slave revolution was seen as a threat. In response, Thomas Jefferson called for the isolation of Haiti. The U.S., in collaboration with France, enforced a commercial embargo of Haiti in the early 1800s, which immediately crippled prospects for Haiti’s economic development by ensuring that the newly independent country was effectively prohibited from participating in the international economic community [6]. In 1827, France sent 41 warships to Haiti demanding compensation from the Haitian people for stealing themselves--as French property--from the French. Without weaponry or money for another battle, the Haitian people agreed to pay France a sum of 150 million francs (equivalent to US$21 billion today), a debt they were unable to repay until 1922 [7].

Thus, Haiti began its independent life economically isolated and weighted down by crushing debt. Under the guise of internal unrest and to protect American business in Haiti, the U.S. Marines invaded Haiti in July 1915. They created and trained the Haitian Army and remained an occupying force until 1934 [8]. Armed popular resistance to the occupation began immediately following the invasion and continued for the next 29 years, though opposition and dissent were violently suppressed [9]. During that time, a small minority of Haitian elites consolidated their political and economic control over Haiti, bringing brutal dictator François “Papa Doc” Duvalier to power in 1957 [10]. His son, Jean-Claude “Baby Doc” Duvalier, succeeded him in 1971. When Jean-Claude Duvalier fled Haiti in 1986, he left behind a country ruined both economically and politically. The legacy of this almost 30-year regime still haunts Haiti today, including the US$900 million debt incurred by Duvaliers’ personal spending [11].

The nascent grassroots movement that brought the first democratically-elected Haitian government and President Jean Bertrand Aristide to power in 1990 was deposed by a United States-backed coup d’état in 1991 [12]. The military dictatorship plundered the national treasury, and inflicted widespread violence and injustice on the general population [13]. After three years of a brutal regime, President Aristide was reinstalled in 1994 [14]. He finished his term and democratically handed power to President René Préval. Aristide was re-elected in 2000. However, disputes over run-off elections for several parliamentary seats served as a pretext for renewed foreign involvement in the Haitian political process [15]. Consequentially, the U.S. and the Inter-American Development Bank blocked all aid to the public sector of Haiti [16]. Military force, covertly backed by the U.S., France, and Canada, was also used to destabilize the Aristide government [17]. On February 29, 2004, President Aristide was removed from power against his will and taken to the Central African Republic on an unmarked U.S. military plane [18]. The U.S. Marines entered Haiti that morning followed by the United Nations peacekeeping mission, MINUSTAH, in March 2004.

Two years of extreme violence ensued under the U.S.-backed “transitional government.” Unrest and pro-Aristide protests often resulted in deaths among urban poor in the slums of Cité Soleil and Belair [19]. Finally, the 2006 elections returned President René Préval to power.

Interventionist political and economic policies imposed on Haiti by powerful countries have crippled the country’s ability to express self-determination and have resulted in Haiti’s impoverishment. Today, Haitians continue to struggle under the crushing burdens of insurmountable international debt, poor health care, lack of access to clean water, and the effects of the international food crisis [20]. Added to this are the desperate conditions created following the January 2010 earthquake, and the cholera epidemic that struck the country later that same year.

In understanding the history of Haiti and listening to our patients, friends and colleagues – 90 percent of whom are the rural poor – PIH believes that health and dignity will only be achieved if we engage in a struggle for justice and democracy in Haiti. To this end, the Institute of Health and Social Justice (IHSJ) has engaged in a number of advocacy initiatives to benefit Haiti, ranging from collaborating with other organizations to investigate, document and publicize the harmful effects of withholding loans to Haiti, to examining whether food aid to Haiti leads to food security, improving how foreign aid is delivered in Haiti and eliminating Haiti’s debt to international financial institutions. In addition, the IHSJ works to draw attention to the impoverishment of the public sector by highlighting PIH’s work in supporting the Haitian Ministry of Health at all levels.

For a greater understanding of Haiti and its place in the world, one of the best resources is Paul Farmer’s Uses of Haiti.

Health in Haiti

By almost any measure, Haiti is one of the sickest and poorest places on our planet. A mere hour and a half flight from Miami, the health disparities between Haiti and the United States are staggering. In 2008, Haiti ranked 148th out of 179 nations surveyed in the UN’s Human Development Index, the lowest in the Western Hemisphere [21]. At 61.3 years on average, Haitians have the lowest life expectancy in the Western Hemisphere compared with the composite average of 73.4 years for people living in Latin America and the rest of the Caribbean [22]. Infant and maternal mortality rates in Haiti are equally appalling: 57 per 1,000 live births and 630 per 100,000 live births respectively [23]. This is compared to an average infant mortality rate of 20.2 per 1,000 live births and 89.2 maternal deaths per 100,000 live births respectively for the rest of Latin America and the Caribbean [24].

Today, Haiti is also burdened by the highest HIV prevalence in the hemisphere, representing nearly 50 percent of the known HIV infections in the Caribbean [25]. Tuberculosis remains endemic and is a significant cause of mortality [26]. Malaria, nearly non-existent in many other Caribbean countries, remains a deadly problem in Haiti [27]. In 2004, diarrhea was found to be the third leading cause of death for children under 5 in Haiti, accounting for 17.9 percent of deaths [28]. Even simple prevention measures, like childhood vaccinations, are woefully lacking [29].

Despite the significant health concerns in Haiti, what remains perhaps even more shocking is the utter lack of public health, sanitation and health care infrastructure. Haiti lacks the financial, infrastructural and human resources to deliver crucial preventive health and medical services to its citizens. There are only 2.5 doctors and 1.1 nurses per 10,000 people [30], a paltry figure when compared to the 19 doctors and 18 nurses available per every 10,000 people in the neighboring Dominican Republic [31].  Additionally, most of these doctors and nurses are concentrated in urban areas [32].

Prior to the January 12, 2010 earthquake, Haiti had, on paper, a well-organized public health system. Nationwide, there were 371 health posts, 217 health centers, and 49 hospitals [33]. However, the presence of a health post did not guarantee health services. Many did not function at all or were open just a few hours a day; few had supplies beyond basic vaccines and an unpredictable supply of medicines available only on a fee-for-service basis [34]. Many of these health centers were destroyed in January’s earthquake. According to the WHO’s 2010 World Health Statistics Report, Haiti spent 9.2 percent of its total national expenditure on health in 2007, which amounts to just US$8 per person as compared to US$4,703 per person in the United States. In 2007, 57.4 percent of health expenditure in Haiti was out of pocket [35].

Advocating for Health as a Public Good and Human Right

In 2002, PIH/ZL was chosen as a sub-recipient of funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria. It was the first significant money that the global community had offered for the treatment of these diseases. That year, PIH made a strategic decision that forever changed the scope of our work: we recognized that working to build, rebuild, support and staff health care clinics had to be done through the public sector in order for health to truly become a human right in Haiti. The work started with the refurbishing, staffing and stocking of one small public clinic in the town of Lascahobas, Haiti.

Today, PIH/ZL supports 15 public health centers and hospitals, trains and supports staff, and provides essential supplies, medicines and equipment in two states (known as departments) in Haiti – the Central Plateau and Artibonite. These clinics, centers, and hospitals now reach a combined catchment area of roughly one and a half million people. In July 2010, PIH/ZL and the MOH broke ground in on a state-of-the-art, 320-bed teaching hospital in Mirebalais. It will be a national referral facility, the flagship of our efforts to help rebuild Haiti’s health sector. The new hospital will be equivalent in capacity to all 15 of the sites in which PIH currently works in Haiti, combined, and will offer clinical facilities. Read more about the Mirebalais project.

Our approach in Haiti contributed to PIH’s invitation from the governments of Rwanda, Lesotho and Malawi to engage in partnerships, not only to provide health care but also to strengthen the public sector. The IHSJ uses these examples in its advocacy with partners on issues such as the health system strengthening and increased funding for global health.

Water

In June 2008, Partners In Health—along with its Haitian sister organization Zanmi Lasante (ZL), the NYU Law School’s Center for Human Rights and Global Justice (CHRGJ) , and the Robert F. Kennedy Center for Justice and Human Rights released an 87-page report, called “Wòch nan Soley: The Denial of the Right to Water in Haiti.”

Read the entire report online.

Loune Viaud, director of operations and strategic planning at Zanmi Lasante, spoke at a press conference announcing the release of the report: “We have to stand up for what's right. What is right is for the Inter-American Development Bank (IDB) and the international community to stop playing with the lives of innocent people.” Viaud and the rest of the investigative team worked for six years to bring the story of the IDB loans to light. During that time, Haiti’s water system continued to deteriorate. The report found that:

• Public water systems in Haiti are rarely available throughout the year and close to 70 percent of the population lacks direct access to potable water at all times.
• The percentage of the population without access to safe drinking water has increased by at least seven percent from 1990 to 2005.
• Infectious diarrhea was the second leading cause of death in Haiti in 1999, and gastrointestinal infection was the leading cause of mortality for young children. These preventable diseases result primarily from unsafe drinking water and poor sanitation [36].

In October 2010, Haitians were struck by an outbreak of severe cholera, a disease which had been eradicated in Haiti for nearly 50 years. In the outbreak’s first 40 days, the epidemic had spread to every province in the country, claiming an estimated 2,000 lives in its path [37]. Though oral rehydration and antibiotics can shorten the course of illness, decrease the volume of diarrhea, and limit transmission, most Haitians lack access to quality health care, water and sanitation. Until funds are used to strengthen the public infrastructure and develop a reliable and safe public water supply, acute disasters such as the cholera epidemic will only exacerbate the chronic problems of poverty and disease that have existed in Haiti for centuries.

Food Security

In December 2010, PIH, ZL, the NYU Law School’s Center for Human Rights and Global Justice and the Robert F. Kennedy Center for Justice and Human Rights released a second report called “Sak Vid Pa Kanpe: The Impact of U.S. Food Aid on Human Rights in Haiti.” The title of this report draws on a Haitian proverb, which laments that a sack cannot stand if it is empty—a powerful metaphor for the importance of food and sustenance to one’s capacity to “stand” and function.

Drawing on both human rights and public health methodologies, the report finds that while U.S. food aid may provide partial nourishment to many people, the way in which it is procured, delivered, and administered often interferes with basic human rights by failing to improve long-term food security to Haitians. The report sets out concrete recommendations calling on the U.S. government to transform food aid in accordance with human rights principles so that food in Haiti is: economically and physically accessible; adequate in quantity, quality, and nutrition; culturally acceptable; available; and sustainable.

Read this report. 

Current State of Affairs

A catastrophic 7.0 earthquake hit very nearby Port-Au-Prince on January 12, 2010, further setting back Haiti’s efforts to move past instability and debt. Infrastructure was destroyed, and roads, homes, hospitals, schools, the capital building, the airport, and UN Headquarters, among others, were badly damaged. Over 230,000 people died, and over 1.5 million were displaced [38].

On February 5, 2010, U.S. Treasury Secretary Timothy Geithner announced his support of debt cancellation and grants, rather than loans, for Haiti. At the G7 meeting in Canada, finance ministers also voiced support.

The U.S. Congress worked to turn these commitments into reality. On February 2, 2010, Representative Maxine Waters (D-CA) introduced the Haiti Debt Relief and Earthquake Recovery Act of 2010 (HR4573). The bill, as described by its official summary, calls for Secretary Geithner to press U.S. officials at the IMF and other “multilateral development institutions” to work for:

1. cancellation of all remaining debts owed by Haiti to such institutions;
2. suspension of Haiti's debt service payments to such institutions; and
3. before February 1, 2015, provision of emergency, humanitarian and reconstruction assistance from such institutions to Haiti in the form of grants or other non-debt assistance.

It also urges the Secretary himself to instruct the U.S. Executive Director of the IMF to advocate the use of some of the windfall profits from the ongoing sale of certain gold to provide debt stock relief, debt service relief, and, before February 1, 2015, grants for Haiti.

The House passed the bill on March 10, 2010, and the Senate followed March 26. President Obama signed the bill on April 26, and it became law. On May 28, 2010, the World Bank cancelled Haiti’s US$36 million remaining debt. (Read press release) 

On July 21, 2010, the IMF Executive Board finally cancelled Haiti’s debt, equivalent to US$268 million. However, at the same time, they issued a new, $60 million loan “to support the country’s reconstruction and growth program [39]." Read the IMF’s entire press release.

On July 1, 2010, the U.S. House of Representatives passed amendments to the 2010 Supplemental Appropriations Bill (HR 4899), which included $2.9 billion in aid for Haiti [40]. Late on July 27, the House passed a final version of the bill, which was then sent to the President for his final signature. More information and full text of the bill.

Recent Advocacy

The devastation of the January 12, 2010 earthquake drew the international public’s attention to Haiti. Individuals and private organizations in the U.S. alone gave nearly US$1.2 billion toward relief efforts [41]. Despite this attention, the damage wrought by the earthquake, combined with a fragmented assistance approach, made distribution of aid inefficient. In addition, much of the relief efforts lacked an emphasis on social justice and human rights.

On January 27, 2010, Dr. Paul Farmer testified at the “Haiti: From Rescue to Reconstruction” hearing of the U.S. Senate Foreign Relations Committee, advocating for basic human and economic rights to direct U.S. policies of aid and rebuilding. Read the full text of this testimony.

Loune Viaud, Director of Operations for Zanmi Lasante, submitted testimony to the Inter-American Commission on Human Rights during a “Hearing on the Economic and Social Rights Situation in Haiti following the Earthquake and the Human Rights Obligations of OAS Member States.” On March 23, 2010, her daughter, Maureen Plaisimond, delivered her testimony on “how international assistance has supported our work, and […] how such assistance can have—and has had in some cases—a detrimental impact on fundamental economic and social human rights such as access to water, adequate food and healthcare.” Representatives from the NYU Law School’s Center for Human Rights and Global Justice, and the Robert F. Kennedy Center for Justice and Human Rights, the Bureau des Avocats Internationaux (BAI), and the Institute for Justice and Democracy in Haiti (IJDH) also participated in the hearing.

PIH/ZL’s Haitian staff grew from 4,000 to over 5,500 following the earthquake. The organization’s efforts in Haiti have expanded dramatically, in an effort to address both the immediate medical and infrastructural needs of the population, and also to ensure that a human rights-based and partnership perspective is emphasized during rebuilding. In a time of intense international focus and aid pouring in, a push for PIH’s longstanding model—a public-private partnership and a rights-based approach—has become even more essential.

These principles and policies guide PIH’s efforts to direct the attention of the international community to the voice of the Haitian people and to strengthening the Government of Haiti’s ability to fulfill its citizens’ human rights.   

Complimenting the role of President Bill Clinton, Dr. Paul Farmer, and staff at the United Nations Office of the Special Envoy for Haiti (OSE) and PIH participated in preparatory meetings for the March 31 Haiti Donors’ Conference in New York City. Those attending relayed feedback from our team on the ground and shared a framework and principles for donor, implementer and NGO transparency and accountability. Working with the RFK Center, the CHRGJ, and the IJDH, PIH co-authored a letter, signed by over 300 NGOs, outlining those recommendations.

On July 27, both Loune Viaud and Dr. Farmer testified in front of a Congressional Black Caucus hearing in Washington, DC, called "Focus on Haiti: The Road to Recovery - A Six Month Review." More information the complete text of these statements.

To advocate for maximum relief funds as well as a new and more coordinated approach to policies and programs, PIH has maintained a consistent presence on Capitol Hill and with the current U.S. Administration. PIH staff members have participated in individual meetings with members of Congress and many briefings, and have appeared on panels hosted by the Congressional Black Caucus, TransAfrica Forum, the Black Philanthropic Alliance, and others.

Through the use of the PIH social media network and website, PIH has posted videos made with IJDH and others documenting the conditions in camps in Port-au-Prince. In addition, PIH’s Haiti Chief of Mission, Louise Ivers, and her Special Assistant, Kimberly Cullen, collaboratively conducted a study of the economic and social human rights at one of the camps where we have a medical clinic. The results of the study were recently published in the Health and Human Rights Journal.

Both the service and advocacy work will be long-term. Continued discussions and advocacy will be needed for bilateral and multilateral donors to encourage actual disbursement of the nearly US $10 billion committed at the 2010 Donor Conference. Along with the OSE and other partners, PIH will continue to advocate for better implementation of foreign aid-funded projects and to channel more aid through the Haitian government in order to strengthen both their systems and their ability to fulfill their citizens’ human rights.