Effects of Continued Economic Sanctions Against Haiti
- Dr. Paul Farmer on the Connection Between Suffering and the Aid
Embargo
- Briefing Paper on Haiti's Deteriorating Health Conditions
- Water Alert: Sharp Decrease in Access to Potable Water
By: Dr. Paul Farmer:
March 2002
Haiti: Unjust Aid Embargo During Health Emergency
I write to report on conditions in Haiti's central plateau, where we
have for the past 18 years delivered health services to the region's
poor. The current climate is one of continued deterioration of social
conditions, due in large part to lack of resources, medical personnel,
and a growing burden of disease. The causes of worsening conditions
are many, but it is possible- indeed, imperative- to underline the
direct connection between unnecessary suffering and death and an aid
embargo, which has dramatically diminished the ability of the
public-health system to respond to the needs of the Haitian people.
The Duvalier regime was aptly termed a "kleptocracy," in large part
because of its mismanagement of foreign aid, much of it from the
United States. Since the fall of the Duvalier dictatorship in 1986,
there have been only brief periods in which public-health officials,
in concert with a broad range of partners, have been permitted to
implement a series of projects designed to improve health conditions
in Haiti. The 29-year long regime was followed by military rule and,
within years, by a military dictatorship. Generous aid continued to
flow during much of this time, but very little of it seemed to reach
its intended beneficiaries.
In 1990, democratic elections brought new hope to those working to
improve health conditions in Haiti. A military coup in 1991 brought an
abrupt end to that hope. In central Haiti, we documented both
worsening social and economic conditions and a paradoxical decline in
the number of patients seen: our clinic was targeted by the military
for repression and threats, events we have described elsewhere. The
impact of the military coup on Haiti was severe in the short-term,
with thousands killed outright and hundreds of thousands displaced.
The decline in health status during the following three years was
catastrophic: epidemics of measles and other vaccine-preventable
diseases were reported, as were outbreaks of dengue fever. Infant and
juvenile mortality, and also maternal mortality, are the highest in
the hemisphere. HIV and tuberculosis became the leading infectious
causes of young adult death. Most of these diseases were tightly tied
to increasingly prevalent malnutrition. The nationwide network of
public clinics and hospitals was left to fend for itself, and many
health professionals left Haiti as this network foundered.
All this was to change with the restoration of democratic rule in
1994. At this time, a broad coalition of international donors
announced a plan to commit some $500 million of aid to Haiti. Without
an infusion of capital, it was agreed, it would be impossible to
rebuild Haiti's battered health and social-services infrastructure. A
number of projects designed to revive public health and education, as
well as its transport systems (most roads had been destroyed), were
developed and approved by the Inter-American Development Bank (IADB)
and other funding agencies. For a variety of reasons- none of them
related to the most pressing need in the Western hemisphere- this aid
has never been made available. The intervening years have seen a
resurgence of infectious diseases, a decline in life expectancy (the
only such decline documented in the hemisphere) , and enormous
demoralization among medical personnel.
These strictures became even more pronounced over the past year,
during which a formal aid embargo has been declared by the United
States. This embargo has blocked the IADB-funded projects already
approved by both the Bank and by the Haitian parliament. The
commission fees for the loans are accruing even though no monies have
been disbursed. In fact, in spite of dramatically increased
parliamentary capacity to pass legislation to promote public health,
the government has been prevented from implementing projects supported
broadly by the Haitian people. The aid embargo has in effect rendered
the Ministry of Health incapable of reviving the national network of
clinics and hospitals; even vaccination programs have faltered. Again
paradoxically, a number of clinics and hospitals have been abandoned
by both patients, who cannot pay for medications, and by medical
personnel. Cuban medical aid, though admirable, has been restricted
largely to medical personnel. Without money and medications, the
impact of such aid is sharply limited.
Allow me to sketch the impact of these processes on the 80-bed
hospital of which I am the medical director. With a staff of 8 Haitian
physicians and a large corps of community health workers, Zanmi
Lasante is one of the largest charity hospitals in Haiti. We have
never received significant government assistance or funding from the
IADB or USAID; thus we are in a sense neutral observers of the events
described above.
In another sense, however, we are victims of the collapse of the
public-health system. As clinics and hospitals in the region close or
turn away patients due to their inability to pay, the patients have
come to our facility. In the Departement du Centre, where our facility
is based, the commune of Thomonde, with 40,000 inhabitants, was
without a single doctor or nurse during the past year. As a result of
faltering or poor services elsewhere in the region, we routinely
receive 300 patients per day, which has overwhelmed both our staff and
our resources. The Haitian Ministry of Health, the only institution
with a mandate to serve the entire population, has been a willing
partner but has been strapped by such financial constraints that its
assistance has been limited to training.
To attempt to sketch the impact of the aid embargo on social
conditions and our capacity to respond to grave health problems, allow
me to cite certain examples:
· Over the past year, our general ambulatory clinic has seen an
enormous increase in demand. We are staffed to receive no more than
25,000 visits per year, but will this year see an estimated 60,000
patients. Meanwhile, visitors to neighboring facilities have found
them to have very few patients. While several neighboring facilities
remain open, they sell or prescribe medications at prices that are
beyond the reach of the population, over 80% of which lives in
poverty.
· HIV continues to spread within Haiti. Although the Haitian
epidemic has been contained more effectively than in many African
countries, it is the gravest in the hemisphere. A national AIDS plan
was advanced at last year's United Nations Special Session, with First
Lady Mildred Aristide leading the delegation, but this plan- widely
regarded as sound by experts- remains unfunded. Meanwhile, U.S. and
World Bank assistance for HIV prevention has continued to flow to
other less gravely affected countries in the region (at one point, a
"Caribbean-wide" AIDS initiative with a proposed budget of over $100
million had not a penny allocated to the country with an estimated
65-70% of all the region's cases).
· Tuberculosis remains a major cause of adult mortality. Again, the
prevalence of TB is thought to be the highest in the hemisphere, with
active case finding suggesting prevalence more than ten times as high
as other Latin American countries. , At the same time, it is of note
that the Haitian National TB Program has continued to receive
international donor support and has thus managed to continue to
procure and distribute medications. We have not experienced drug
stockouts, even though we receive all first-line drugs from the
Ministry, and thus although our case rates are rising, mortality
remains low within our catchment area and others working in concert
with the National TB Program.
· We have registered a rise in trauma cases due in large part to
road accidents. The sequelae of accidents are more serious, since
patients are required to travel farther to receive care and many
require, and do not receive, the care of orthopedic and trauma
surgeons.
· Malaria remains a major contributor to anemia and death. In our
facility, malaria is the leading single diagnosis during the rainy
season. Deaths continue to occur, even though Haiti has not yet
registered chloroquine-resistant cases. Lack of access to care remains
the primary problem.
· Polio, previously believed eradicated from the Western hemisphere,
has again resurfaced on the island. Whether wild type or
vaccine-related strain, polio virus will continue to spread if
national vaccination efforts are not supported through Ministry
programs, since national coverage is imperative.
· We have documented outbreaks of anthrax, meningococcus, and
drug-resistant tuberculosis. The degree to which these pathogens
spread will be determined largely by the capacity of the public health
system to respond.
Of course claims of causality are always difficult to prove, but
whether these conditions are caused or not by international policies,
it is clear that aggressive humanitarian aid could have an immediate
and salutary impact if it can be channeled through institutions with
national reach. Increasingly, however, aid has been decreased or
funneled to non-government organizations that make largely local
contributions. I have worked for almost 20 years in Haiti and have
seen U.S. aid flow smoothly and generously during the years of
Duvalier dictatorship and the military juntas that followed. As a U.S.
physician, I believe it shameful that the current embargo has been
enforced during the tenure of a democratically elected government.
Such policies are both unjust and a cause of great harm to the Haitian
population, particularly to those living in poverty.
Paul Farmer, M.D., Ph.D.
Medical Director Zanmi Lasante and Professor Harvard Medical School
Briefing on Deteriorating Health Conditions:
March 2002
BRIEFING PAPER ON HAITI'S DETERIORATING HEALTH
CONDITIONS IN WAKE OF US-LED FINANCIAL EMBARGO
THE UNITED STATES RESISTS HUMANITARIAN CALLS TO RELEASE AID
AND LOANS PROMISED FOR HAITI'S HEALTH SERVICES AND SOCIAL CONDITIONS
"There are too many needs in Haiti going unaddressed and we should not
be
holding up any funds. We are putting politics and process above the
needs of
the Haitian people." Andrew Cuomo, February 20, 2002 on a recent
visit to
Haiti where he toured the maternity ward of the ailing State General
Hospital
Background:
At the urging of the United States, funds to the government of Haiti
are being withheld by the United States, the European Union, the
International Monetary Fund (IMF), and the Inter-American Development
Bank (IDB). In early 2001, the government of Haiti met all the
conditions for the approval of the IDB loans, which are for health and
accompanying development, including satisfying all arrears owed to the
IDB. The IDB subsequently approved the loans to Haiti and were ready
to disperse the funds when the US caused them to be halted ( i ).
Although the IDB acknowledges that this situation is unprecedented,
the government of Haiti is being penalized with a charge of $79,000
per month in credit commissions to the IDB on loans, which have yet to
be disbursed.
The first phase of the IDB loans is to address quality and access to
healthcare through targeted tasks such as construction of low-cost
community health centers, training of personnel, purchase of basic
materials, providing of healthcare services to 2 million Haitians (25%
of population), including pre-natal, post-natal care, primary dental
care, treatment of contagious diseases. The ultimate objective is to
reduce the high infant mortality rate, reduce the high juvenile death
rate, and reduce the birth rate ( ii ).
Current Status of Healthcare in Haiti:
With the current financial sanctions taking a toll on Haitians and the
delivery of healthcare, the original statistics cited in 1998 with the
signing of the loan agreements between the IDB and the government of
Haiti pale when compared with today's realities as follows ( iii ):
· Child mortality rose from 74 deaths per 1,000 to 80;
· Juvenile death rose from 131 deaths per 1,000 to 149 in the rural
countryside;
· The birth rate rose from 4.6 to 4.7 and as high as 7.6 in one of
the poorest sanitary departments.
Leading Healthcare Providers in the NGO Community of Haiti Call for
Immediate Release of the IDB Health Loans:
Dr. Bill Pape, co-founder of Centre GHESKIO, the oldest AIDS treatment
and research institution, wrote to the IDB president urging that the
health loan be released because, "a battle against AIDS is directly
linked to the reorganization of the health system."
Dr. Paul Farmer, medical director of a private health facility in
Haiti's Central Plateau that treats patients infected with HIV/AID,
tuberculosis and other diseases, reports that "the aid embargo has in
effect rendered the Ministry of Health incapable of reviving the
national network of clinics and hospitals." Dr. Farmer's facility,
which normally receives no more than 25,000 visits per year, will this
year see an estimated 60,000 patients. He attributes this rise to,
"dramatically diminished ability of the public-health system to
respond to the needs of the Haitian people. The Ministry of Health,
the only institution with a mandate to serve the entire population,
has been strapped by financial constraints."
Assistance through the NGO sector is simply not enough and is no
substitute for a comprehensive public health policy. In its 2001
newsletter, the Haitian Health Foundation, a non-profit organization
working in Haiti wrote, "the number of villages that we serve has
grown from 15 to 92 with a population that now stands at more than
200,000. Despite this dramatic increase, USAID has failed to keep
pace."
According to Dr. Farmer, although the Haitian HIV/AIDS epidemic has
been contained more effectively than in many African countries, it is
the gravest in this hemisphere. World Bank assistance for HIV
prevention has continued to flow to other less gravely affected
countries in the region but not to Haiti. A one million dollar
pledge of funds by the IDB for Haiti, made 5 months ago, even when it
was criticized for its disproportionate allocation of funds to
administrative costs versus the actual treatment of AIDS, has yet to
make it to Haiti.
In a recent visit to Haiti, Congresswoman Carrie Meek, citing
worsening health indicators, said, "It is morally correct to release
the aid," and Congressman John Conyers said that resources, materials,
food and assistance "should be coming into Haiti unabated!"
The US Fights Back Against Humanitarian Calls for Release of Health
Monies:Despite the alarming impact of the sanctions on Haiti which
have caused an increase in preventable and treatable diseases and a
higher mortality rate, U.S. Secretary of State Colin Powell, stating
that, "we have questions about providing that kind of assistance [to
the government of Haiti]," stood firm recently against the
recommendations made by the 15-nation CARICOM block who have called
for the lifting of the sanctions.
Despite Obstacles, the Government of Haiti Continues to Address Health
Needs Despite tremendous obstacles and decreasing resources, the
government of Haiti (GOH) has made some important strides in the
health sector:
In October 2001, the GOH completely renovated and reopened the School
of Midwifery;
Haiti is part of an important 3-country HIV/AIDS trial vaccination
program;
New healthcare centers were opened in three municipalities, St.
Louis du Sud, Thomazeau, and Raboteau;
New healthcare centers were opened in three municipalities, St.
Louis du Sud, Thomazeau, and Raboteau;
Renovations of existing health centers and/or hospitals have been
completed or are underway:
· St. Catherine in Cite Soleil;
· The operating room at the Port Salut health center;
· A modern operating room was added to the hospital in Jean Rabel;
· The Miragoane public hospital;
· The Cap Haitian public hospital;
· The pediatric ward of the St. Marc public hospital;
· The public hospital in Gonaives;
The morgue at the State University Hospital was fully renovated,
and doctors were trained in forensic medicine;
The GOH's cooperation with Cuba has lead to the expansion of the
number of physicians in areas of the country with no doctors;
The GOH initiated a salt iodination project to combat iodine
deficiencies reported to affect 10% of the population;
The government initiated an aggressive campaign to vaccinate
children against measles, rubella, polio, and other childhood
diseases.
1 On July 21, 1998, the Government of Haiti (GOH) and the
Inter-American
Development Bank (IDB) signed a 22.5 million dollar loan for Phase I
of a
project to decentralize and re-organize the national healthcare
system. The
GOH was required to contribute 2.5 million dollars to this project.
In
October 1998 the GOH's Ministry of Health presented the IDB loan
agreement to
the 46th Legislature for ratification; the Haitian parliament was, at
the
time, dominated by the political party OPL, now leading spokesparty
for
Convergence Democratique, a platform of opposition parties that
continues to
oppose the release of this and other humanitarian assistance to the
GOH. The
legislature's term expired in January 1999 without ratification of the
IDB
contract.
In October 2000, after the installation of the 47th Legislature
the new
parliament immediately ratified the IDB health project along with 3
other
vital IDB loan agreements for education, potable water and secondary
roads.
The GOH and IDB collaborated immediately to update and revise the
health
project. On March 2, 2001 when the new government was installed, the
Minister of Health notified the IDB that the conditions required of
the GOH
under the loan agreements had been fulfilled. Later that month, with
the
verbal assurance from the IDB that the health loans and 3 accompanying
development loans would indeed be funded, the GOH satisfied all
arrears owed
to the IDB.
In April 2001 at the Summit of the Americas in Quebec, the IDB
informed
the GOH that there was nothing precluding the release of funds to
Haiti,
except for authorization by the U.S. On May 15, 2001, notwithstanding
the
fact that still not one penny of the 22.5 million dollar health loan
or the
other 3 loans had been funded, the IDB advised the GOH that it was
being
charged and would be required to pay a "credit commission" of 0.5% of
the
entire balance of undispersed funds effective 12 months after the date
of
approval of the loans. Based on calculations provided by the IDB,
every
month that political "crisis" is allowed to endure and approved loans
from
the IDB are not dispersed, the GOH would be required to pay $79,000 a
month
in credit commissions alone.
In a letter dated June 4, 2001, the IDB acknowledged that, "the
position
of certain members of the IDB Administrative Council regarding the
situation
in Haiti is temporarily preventing the institution from strictly
conforming
to the norms and procedures agreed to with respect to the management
of the
project [with Haiti.]" And that in this "unprecedented situation", it
was
awaiting the green light from either the Organization of American
States
(OAS) or "major partners" of the IDB's Administrative Council, to go
forward
with the loans. The IDB further acknowledged that, "the Minister of
Health
extended considerable efforts to elaborate the necessary support
documentation and has satisfied the pre-conditions." The letter goes
on to reaffirm the inability of the IDB to "honor its commitment" and
requests that the GOH advance monies to the ministries of health,
education, and public works, "since the preconditions have been
satisfied", with the assurance that this advance would be reimbursed
by the IDB once the loan was funded.
To date, the loans, totaling 145.9 million dollars, have not been
funded. The "authority" sought from the OAS or the IDB's "major
partners" has not been given, even as the GOH has made substantial
progress towards the resolution of the political crisis with the
resignation of all contested senators and a term reduction agreed to
by all members of parliament elected May 2000 -- the pre-conditions
under the OAS resolution for the "normalization of relations between
Haiti and the international financial institutions."
11 During Phase I, the project targeted four of Haiti's ten sanitary
departments, the goals were to:
Improve the quality and access to public and private health
services;
Increase the efficiency of services at a national level; and
Develop innovative models for healthcare services able to be
reproduced at the national level.
Over the 3-year period of Phase I, the following was to be
accomplished:
Technical assistance in the 4 sanitary departments;
The training of Haitian human resources;
Purchase of basic equipment and material;
Construction of low-cost community health clinics;
And the provision of the below listed primary healthcare services
to 2
million Haitians, 25% of the population:
· Complete health care services for all children;
· Pre-natal and post-natal care;
· Reproductive healthcare;
· Treatment of contagious disease;
· Surgical emergencies;
· Essential medicines;
· Health education; and
· Primary dental care.
The project's goal was to:
Reduce infant mortality rate from 74 deaths per 1,000 births to 50
deaths per 1,000 births;
Reduce juvenile death rates from 131 deaths per 1,000 births to
110 deaths per 1,000 births;
Reduce the birth rate from 4.6 to 4.
These statistics were recorded in 1998 at the signing of the loan
agreements. Since then, there has been an increase in the infant and
juvenile death rate and an increase in the overall birth rate:
· Child mortality rose from 74 deaths per 1,000 to 80;
· Juvenile death rose from 131 deaths per 1,000 to 149 in the
rural countryside;
· The birth rate rose from 4.6 to 4.7 and as high as 7.6 in one of
the
poorest sanitary departments.
111 Alarming Health Indicators and HIV/AIDS
Other recent health indicators in Haiti are alarming:
62% of all births are not followed by any post natal care; in the
rural
countryside, that figure jumps to 71%;
23% of all births take place outside a health facility;
24% of all births are not accompanied by any healthcare
professionals;
Only 34% of infants between the ages of 12 and 23 months are fully
vaccinated;
39% of children under 5 have, or have had, acute respiratory
disease;
The maternal mortality rate is 523 deaths per 100,000 deliveries;
On the HIV/AIDS front, the infection rate is nearly 5%, with
30,000 new
cases annually.
Only 4% of woman questioned for a 2001 health survey and 6% of the
men admit to ever having been tested for HIV/AIDS.
Although the World Bank acknowledges and claims "concern" for a
worsening poverty in Haiti, it issued a statement on February 8,
2002, that it would not extend any new credits for Haiti because of
the "political crisis."
Distances Traveled by Haitians for Access to Health Care Reinforces
Need for
Decentralized Approach Adopted in the Blocked IDB Health
Project
According to the most recent survey here are estimates of
distances that must be traveled by urban and rural residents to reach
3 categories of health facilities in Haiti:
Health Facility Distance % of Rural Population %Urban
Population
Hospitals Less than 5 kms 8.2%
65%
5 to 14 kms 27% =
26.6%
15 kms or more 59.2% =
8.4%
None available 5.6% =
-
Health Clinics Less than 5 kms 34.9% 83%
5 to 14 kms 31.2% =
13.1%
15 kms or more 34.0% =
3.4%
None available -
-
Dispensaries Less than 5 kms 53.7% 89.8%
5 to 14 kms 24.6% =
7.9%
15 kms or more 16.2% =
2.3%
None available 5.6% =
-
Water Alert:
Contact: Michelle Karshan, Foreign Press Liaison, GOH
March 2002
HAITI WATER ALERT: SHARP DECREASE IN ACCESS TO POTABLE WATER AS THE
U.S.-LED EMBARGO BLOCKS ACCESS TO A 54 MILLION DOLLAR LOAN AIMED TO
EXTEND ACCESS TO POTABLE WATER
"The lack of water for basic human needs is one of the most critical
problems in the country. The lack of access to safe water supply
contributes to poor health and hygiene. Infections and parasitic
diseases, often spread through unsafe water, are the leading causes of
morbidity and mortality in Haiti."
Water Resources Assesment of Haiti, August 1999
U.S. Army Corps of Engineers
The Poorest Pay the Heaviest Price * Unsafe Water, a Leading Cause of
Mortality in Haiti * Only 40% of Haitians Have Access to Potable Water
* Blocked $54 Million Loan to Improve Water Treatment and
Distribution Would Extend Access to Potable Water to the Haitian
People * Alarming Deterioration of Water Supply
Background
Haiti's national system of water treatment and distribution is divided
among three autonomous entities: CAMEP, which services Port-au-Prince
exclusively; SNEP, which services the 28 next largest cities; and
POCHEP, which has in its charge the rural zones. At the end of 1994,
at the end of President Jean-Bertrand Aristide's first term as
president, CAMEP initiated the construction of public communal water
fountains in poor neighborhoods to increase access to potable water at
affordable prices. These fountains are managed by neighborhood "water
committees;" who bill end users and in turn pay monthly charges to
CAMEP. This system has proven to be an efficient and cost effective
method of extending access to potable water to the poorest sectors of
the population.
In 1999, shortly after the government of Haiti (GOH) negotiated a loan
agreement with the Inter-American Development Bank (IDB) to reform the
country's water treatment and distribution system, CAMEP was producing
approximately 100,000 metric cubes of water daily. Although it
registered 27,500 paying residential and business customers, CAMEP was
actually serving up to 630,000 people, which was estimated to
represent approximately 40% of the capital's population. This level
of production was less than half the level required to meet the needs
of all of Port-au-Prince. SNEP was reaching only about 45% of its
targeted population. And POCHEP's 90 hydraulic systems were supplying
only 741 public fountains and 1821 private homes in the entire rural
countryside.
Although the communal fountain initiative provided a sustainable, safe
water supply to thousands, it could not keep up with Haiti's rapid
urbanization and population growth, nor close the gap from decades of
underinvestment. The need for a comprehensive program to reform the
system and increase access to potable water was self-evident.
The IDB Loan to the GOH Would Improve the Level of Services that
Provides Potable Water and Increase Access to Water to the General
Population The IDB potable water loan agreement, like the IDB
development loan agreements for health, education and infrastructure
reform, was signed by the GOH, the president of the IDB, approved by
the Haitian parliament, and had all its preconditions met. However,
to date it remains blocked for disbursement because of a U.S.-led
embargo aimed at forcing political concessions by the GOH to an
obstructionist political opposition with virtually no support from the
population.
This IDB potable water loan project has the following objectives:
Ø To merge the separate water distribution systems into one more
efficient, national water service agency operating under a new
regulatory framework with specialized training for all personnel.
Ø The inclusion of the private sector and the integration of local
water committees in this new water service agency.
Ø Finance the rehabilitation and extension of the infrastructure
required to extend service throughout the country, specifically:
§ At least 10 urban systems and
§ 50 smaller rural systems.
Ø The project forecasted the following increases in access in these
two targeted areas by the year 2002:
§ In draught stricken Port-de-Paix in the rural Northwest of Haiti,
access to potable water would rise from 5 to 39% of a population
estimated at approximately 106,000;
§ In the southern city of Cayes, access to potable water would rise
from 9 to 30% of a population estimated at approximately 162,000.
Ø Other areas serviced by this new water service agency would
register an average 15% increase in access to potable water.
Thereafter, every 3 years, the residential customer base would
increase 5% as a result of the projected re-investment to take place.
Ø The project also forecasted decreases in the levels of diarrhea,
typhoid and malaria, diseases associated with contaminated drinking
supplies.
Ø The project would reinforce the capacities of the new water
service agency to address environmental issues.
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