April 2004

Views expressed are those of the authors, not necessarily of the AFSC.

US Invasion of Haiti Deepens Health Crisis

Paul Farmer, M.D., Ph.D. is the Medical Director of Clinique Bon Sauveur in Haiti, a Professor at the Harvard Medical School, and author of The Uses of Haiti, and Pathologies of Power: Health, Human Rights, and the New War on the Poor, among other works. A biography of Farmer, Mountains Beyond Mountains, by Tracy Kidder, was published in 2003.

Dear Secretary of Defense Powell:

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 notes that "insecurity is highest in Artibonite and Central" departments (regions). 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 power, 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 US 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, US, 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: 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 US direction should make these facilities safe for patients and staff. The rebels 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 area of moral clarity.

To obtain the report from the Pan-American Health Organization, please see www.paho.org/English/DD/PED/haitisituation2004.htm. To learn more about and donate to the Clinique Bon Saveur, see www.pih.org/. To protest the US military takeover of the medical school, please contact US elected officials.

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