A tale of two Haiti(s)

My brother Keddy and I grew up in Karenaj, a then hassle-free neighborhood in the world-renowned city of Cap-Haitien. Although our family had relatives in Saint-Michel de l’Attalaye, an Artibonite county south of Cap-Haitien, we lived far removed from rural Haiti, except for a few sporadic trips to “andeyò” which is the term Haitians use to refer to rural areas. It’s a Kreyòl word derived from the french “en dehors” translated as outside. So my twin and I, we were raised unfamiliar with most traditional food and to a greater extent, the language and culture of Haiti’s rural regions with their complexity and richness.

When our grand-mother passed away, I could feel that the few stories of Saint-Michel along with anecdotes of our elderly’s rural trips had also vanished. But now, as adults and doctors, we’ve managed to visit the entire country apart from Grand-Anse, either during professional endeavors or on personal adventures. As far as we could tell, decades later, differences still persist between how us, city-raised gentlemen, perceive and express reality and how rural populations do. Not only the rhetoric differs but the very elements of culture struggle to collide. During our trips, those gaps even impaired our ability to communicate with the locals. In terms of local tourism, this situation wouldn’t be much of an issue. But consider the heavy toll of such discrepancy when it comes to patients explaining their symptoms or when it comes to us doctors communicating health risks and treatment options.

In the 1970s, as Haiti’s agriculture sector plummeted, people massively moved from rural regions to adjacent towns in search of a better life. Throughout the decades, the dynamics of rural exodus have only made this transit skyrocket. More than half of Haiti’s population now live in cities. Needless to say that the emigrants carry what they have accumulated as a cultural background with them. The vacuum left by such demographic movement and social context leaves the rural areas very vulnerable. Which in turn often leads to city dwellers, with their own culture, to commute to rural areas for work-related projects, many of them provided by NGOs. This is how we found ourselves on a day-to-day journey trying to comprehend each other.

In rural populations, overcoming issues such as academic illiteracy or comprehending the beliefs in magico-spiritual forces is often a pre requisite for creating rapport and therefore to have impact on a patient’s health outcome. But some other concerns are subtler. I recall having examined an old woman named Annia in Saint-Antoine, a neighborhood next to Poupelard avenue, in Lalue, Port-au-prince. The old woman was from the South and had settled in Saint-Antoine less than 2 years prior to her consultation. Visibly uncomfortable, she described her pain to me in those words: as if a stack of millet was being pounded upon with a big pestle. She made it clear: – “The big ones Doc, not the small ones”. Coffee is very much engrained in every Haitian’s life and I’m very familiar with scenes of people pounding coffee roasts in big pestles, it happens in rural zones as in certain towns, but I sure had no idea as to what it feels like. And can’t obviously make the difference between the big and smaller ones, except for their size. While I was expecting her to describe her symptoms using my words, she relied on images of her daily life. As she spoke, even though we speak the same language, I could feel the gap between us widen and as if we were losing each other.

Keddy has also experienced such “language barrier” when he asked a patient from a locality near Montrouis, when she’d last had her period and she casually replied: – “On the last moon”. While he was anticipating an exact date, ignoring when the last moon was or even what that actually means.

It’s not a mere matter of language (French versus Kreyòl) as the concern is raised ad nauseum but instead a collusion between two different cultures, impairing understanding and proper health communication between two people speaking the same language.

These cultural barriers to communication stress the difficulties to assess and address health risks in patients and communities alike. I remember visiting Maniche with a team of Port-au-prince-based health agents. Most of them were hailed from this very Southern locality, and although our job was to raise concern about the safety of a water source, because they used to drink it and were actually baptized in these waters in their youth, it became harder for them to question its quality. The same goes for patients suffering from high blood pressure who dismiss any change in the way they prepare food because they’ve been taught a particular way by a parent since they were kids. Habit is more powerful than science and without the psychological tools of social and behavioral change communication the work of healthcare providers might as well be for naught.

I went back to Karenaj recently. As I sat in furniture that feel older than the city itself, I was thinking that until we reduce the gap between urban and rural realities we will not be able to understand each other, recognize what puts us at risk and heal our common evils. As I thought of my conversation with Annia and the way many pride themselves as educated, I asked myself if we were hardly doing any good. What good is a doctor’s vast knowledge if he can’t even understand his patient, let alone help her improve her behavior? There is not a single way to resolve these differences. But if we at least stop considering distance as difference, maybe we can start learning and improving together.

Questioning Ban Ki Moon’s plan to address cholera in Haiti

Lately, a spotlight has been placed on the United Nations in Haiti. Outgoing Secretary-General, Ban Ki-Moon has delivered pivotal statements at the General Assembly and via the Miami Herald concerning the UN’s response to the cholera epidemic in Haiti. Right now is as good a time as any to remember the critical work that has already been done to eliminate the disease, long before Ban Ki-Moon’s big statement.  Right now is as good a time as any to remember the fact that Haiti’s future lies only in our own hands.

Before 2010, cholera, which mostly affected Asia and Europe centuries ago, did not exist in Haiti. It was imported from Nepal in October 2010 because of the continuous dumping of feces into a river by UN peacekeepers based in Meyes, near Mirebalais, in central Haiti. Weak hygiene and sanitation conditions since the beginning of the last decade, partly due to political instability, facilitated the rapid spread of the disease to the rest of the country. This shows the UN’s direct responsibility in the emergence of the disease in Haiti, a claim which epidemiologists have backed, and which the UN has fiercely denied and hidden over the last few years.

In 2016 the United Nations has suddenly changed their posture in regards to their role in the spread of cholera in Haiti and their response to the epidemic. The first hint at this change of heart came in a report by Philip Alston, a UN adviser criticizing the organization for its disastrous response. “The UN’s explicit and unqualified denial of anything other than a moral responsibility is a disgrace,” he stated. In early December this year, 6 years and thousands of deaths later, Ban Ki-Moon apologized to the Haitian people for the role his organization played in bringing cholera to Haiti.

In his Miami Herald Op-Ed, Ban Ki-Moon revealed the outline for what he called a “new approach to right a wrong” in Haiti. This approach revolves around intense response to outbreaks, reparations to the victims’ families, and long term development strategies to provide safe water to the population. As a physician familiar with the Haitian government’s already laid out plan to eliminate cholera by 2022 and the ongoing instrumental work of human rights advocates to hold the UN accountable, I struggled to find what was new about this proposal. Is the UN simply publicly parroting the existing national plan to eliminate cholera, or are they finally heeding the victims’ unceasing call for justice?

At the beginning of 2013, while the United Nations was still denying responsibility for the outbreak, the Haitian government with support from various international partners, initiated a 10-year cholera elimination plan, with a short-term component ending in 2016. At the time, many criticized this plan as being too broad. Among other things, it aimed to guarantee access to drinking water for 80% of the population. That was quite impossible in the planned timespan, given the lack of resources.

In fact, in 2014, Haiti came close to eliminating cholera. Were it not for repeated cases of vandalism on water systems in several regions among other factors, the strategies put in place would have been successful. The Ministry of Public Health and Population (MSPP) and the National Direction for Drinking Water and Sanitation (DINEPA) have learned from these experiences, and launched the mid-term part of the plan in August 2016 (before the UN’s change of stance ) with support from partners including UNICEF. This part focuses on axes similar to what Ban Ki-Moon introduced as the UN’s new approach: water and sanitation, healthcare services and management, epidemiological surveillance, health promotion, hygiene and nutrition.

While he did acknowledge the ongoing efforts against the cholera epidemic, the public health orientation Ban Ki-Moon outlined in his op-ed is not different from what has been laid as the basis for every actor in the national plan. His proposal uses the language and solutions proposed by advocates that the UN spent the last 6 years denying. Looking back, the path we have traveled in this fight is paved with lessons for Haiti as well as for the world. The General Assembly has agreed to support the new plan to eliminate cholera in Haiti, but I will not forget where the crucial work began and continues. As I continue my travels through various Haitian communities as a Haitian public health researcher or for personal activities, the notion that Haiti’s future lies only in our hands will remain a dear mantra.

Many thanks to Nathalie Cerin for the fantastic editing of this article.

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A Path to Fighting Cholera in Haiti After Hurricane Matthew

The rain was pouring as the car rolled towards Hinche. Kal and I were leading a team of doctors and researchers on a week-long investigation of factors related to the cholera epidemic in Haiti’s Center department a few weeks ago. As we went along the road, we could only look as far as five meters ahead due to heavy rainfall. I vaguely recalled hearing of a Hurricane Matthew forming in the Atlantic Ocean a few days before. The rain beating down on the area known as the “Bas Plateau” (Southern region of the Center) gave me a glimpse of the massive environmental and health consequences such a hurricane would bring to Haiti. My anxiety increased knowing that this specific department was the first, and one of the most severely, affected by the cholera epidemic ever since it was introduced in Haiti in 2010 due to improper waste management by UN peacekeepers.

Hurricane Matthew mostly devastated Haiti’s Deep South, affecting nearly 80% of homes in Jeremie, a coastal town in Grand Anse. Crops, livestock and drinking water systems also perished. As foreseen by health authorities and the population, outbreaks of cholera, which is endemic in Haiti seem to have quickly risen in several localities of the South peninsula. In light of my experience on the field in the Center, I propose a few strategic insights pertaining to cholera elimination in the aftermath of this disaster.

Decision making and public health interventions are more likely to be successful when they include members of the community served.

That is to say, the people from there who hold an attachment to that particular region, who maintain hope in the face of adversity and challenges as in post-Matthew Haiti. In my opinion, the water and sanitation technicians of the municipalities known as TEPACCs embody this idea. They are residents of the respective communities they serve. Oftentimes university students or local professionals, they are responsible for listing water sources and oversee the management of sanitation structures in the most remote areas of the country. The TEPACCs are widely responsible for the safety of the water consumed by most of the population and ensuring that waste is properly disposed.

These workers are familiar with all the localities and their physical and structural characteristics. During our time in Mirebalais, the TEPACCs Grandin and Cameau,  guided us to the remote areas, and informed us on the unspoken truths of these places where cholera has remained for 6 years. The cholera efforts and results all around the country would be far more effective if they were provided the necessary equipment they often lack such as, motorcycles so they can access remote areas easier, computers and cellphones to facilitate communication. In the aftermath of Hurricane Matthew because so many water sanitation structures have been destroyed, offering more resources to the TEPACCs is crucial.

The epidemic situation in the Center also reveals the vulnerability of specific regions where cholera persists in Haiti. Floods may have worsened the contamination of water sources in the South, as shown by more than four hundred suspected cholera cases, unconfirmed as of this writing. However, the focus should not be taken off previously identified zones of cholera persistence such as specific towns or regions in the North, Center, Artibonite and West even when they were not the strongly affected by Hurricane Matthew. Studies show that these zones of persistence play an important role in re-emergence of cholera during the rainy season because the transmission lingers even during the dry season. The increased cases during the rainy season such as the situation in Randel (South) right now- where an outbreak erupted even before the hurricane- is nothing but a mere consequence of cholera enduring in Haiti for 6 years. So, in addition to the added risk that Hurricane Matthew brought, these preexisting persistence zones remain the pressure points on which our attention should remain if we hope to eliminate Cholera on the island.

The reconstruction of water systems and protection of sources should indeed take into account these towns whose vulnerability have not decreased after Matthew. In Mirebalais, I visited a Cholera Treatment Centre (CTC) where there were more than a hundred cases in the last three days at the time of my visit. An officer of an international organization working with outbreak response teams on the field reminded me that the epidemic had been raging long before the hurricane. It is imperative that we do not forget that.

 

La Theme River. Photo credit: Karolina Griffiths

In such a context, I do not share the opinions of some of my colleagues who dismiss the importance of vaccination, thinking it would be a waste of time, money and energy. As a matter of fact, the World Health Organization pledged one million vaccine doses to Haiti that 500,000 people could benefit from. Vaccinations may not the cure to the epidemic, but they can help save precious time and resources while we focus on strengthening our response capacity to outbreaks, improving access to safe water and sanitation, and educating at-risk populations especially in a post-disaster context. Education is crucial for behavior change, because many still believe that “cholera is spread through the air.” One man told us these words right before he nonchalantly dove in the Artibonite River that visibly contains dirt and sewage from the marketplace, the slaughterhouse and the prison.

The effects of Hurricane Matthew will be long term. The challenges of eliminating cholera by 2022 are uncountable. Based on my experience in research on the determinants of the cholera epidemic in the Center department alone, I foresee the benefits of strengthening the TEPACCs in their role, keeping epidemiologic surveillance in known areas of cholera persistence in Haiti and seizing this opportunity to vaccinate at-risk populations to prevent new cholera infections. This will be a heavy task, but this is a time where we, as a people, cannot afford to sink into fatalism or complacency. Hurricane Matthew is surely a step back, but it is also an opportunity to push Haiti forward towards progress and sustainability.

Read the original version on Woy Magazine

 

Why Haitian Doctors Choose To Practice In Haiti

Three months ago, I was granted the opportunity to present the results of an epidemiologic research (scroll down to CO-057) I conducted at the latest conference of the French Society of Pharmacology and Therapeutics; a scientific institute aiming to advance research on drugs and their utilization. Being a local-trained and based doctor in Haiti, I was twice as happy realizing the many promises of medical research for the country. However at the same time, the back of my mind was still being gnawed by the many obstacles afflicting the Haitian health care system. For example, while the epidemiological threats are quickly diversifying, basic data collection and analysis are still lacking. And a flagrant misuse of local capacities is in many aspects a scourge. As the ongoing strike of residents exposes the system’s shortcomings, it is obvious that such structural inadequacies have long resulted in junior doctors’ exodus.

Read “Why young doctors leave Haiti”

But against these odds, many Haitian doctors choose to practice in Haiti, despite increasing promises of improved work environment and better opportunities for doctors in foreign countries. Even among the large community of Haitian doctors practicing abroad, the desire to come back to the motherland is often expressed.

There is no one reason for that desire to stay or come back to Haiti. A colleague told me that Haiti is the only place he feels he belongs and connected to. That regardless of the state of the healthcare sector, he is more likely to stay in Haiti, strong of his familiarization to the Haitian culture and way of life. Some doctors don’t have a choice at all, staying because of family situations such as marriage or a chronically sick child.

As a reason for their coming back to practice in Haiti, a few of my former professors evoked experiences of exclusion, discrimination and racism which have contributed to drive them back where they feel more appreciated and needed. One day, as I was in Brussels for a medical internship, as I handed my passport to an office staff member, I was startled as he shouted to me how chaotic of a country Haiti is. That experience helped me catch a glimpse of what many might be enduring abroad in regards to discrimination pertaining to their origin.

Deep inside, I know that personal reasons such as lifestyle, family situations or unfortunate experiences abroad are not sole factors to embrace Haitian medical practice. As a matter of fact, while most doctors who leave always give me clear reasons why they do, most doctors who stay never seem to be able to give me a concise reason why they do. What is for sure is that whatever the reasons given, they are almost always associated with a profound feeling of patriotism and a sense of duty when it comes to practicing medicine in Haiti.

In fact, as I described in many of my articles, factors such as a lack of capacity and initiative hold back the Haitian healthcare system. But regarding its current state, one of my mentors affirmed that Haitian doctors, as every citizen, need to redefine their relationship to Haiti instead of abandon it. According to him, overcoming our shortcomings in regards to health care is a patriotic duty. But how many doctors are there, visionary enough to make it their mission to stay or come back here and try to improve what can be? I am honored to know and work with many of them. As I was recently discussing with two senior doctors, they consented that leaving might earn them less stress but also less happiness. Their choice was motivated years ago, ever since their career started back in the 1980s, by the ambitious project to train generations of doctors in Haiti to solve Haiti’s health issues. Let me clarify that leading a health-related project in Haiti is barely an easy task. I know that because the organization I co-founded, integrAction, has long been trying to find a working strategy to accomplish its mission which is to improve health literacy in Haiti. But with the experience I gathered, I realized that an often silent sense of patriotism plays a key role in keeping people pursuing their project. For me, there is no doubt that this is the most important reason why doctors still choose to practice in Haiti over many other choices. It is a crucial driver and that’s good because the fact is that Haitian doctors are critically needed on their land.

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This leads to another reason to practice in Haiti: the desire to cast a stone. Even though it’s a plausible argument for countless people, I’m not referring here to the year of service provided in exchange for the State’s investment in training doctors. In a broad sense, Haiti has nourished the personality and imagination of everyone who has spent time here. It has shaped who the people are- doctors included- through a complex net of trial and error, frustration and victories. And as the saying goes, much is often required from whom much is given. For a lot of Haitian doctors, staying in Haiti helps them to be useful and contribute where they are needed. And they all agree that politicians and those in charge of the health sector have the obligation to foster an adequate and coordinated work environment for more and better impact.

In the midst of a health system in crisis with no apparent short term resolve, my questioning the motives behind Haitian doctors’ choice to keep a practice in Haiti was both justified and eye-opening. It helped me determine where to look at in order to inspire the future doctors of this country. A mixture of personal preferences seem to be an important factor but patriotism and the aspiration to contribute to the community are also deeply ingrained. As Haitian doctors continue to build and struggle against all odds, the need for advocacy for an improved work environment and opportunities to live a fulfilling life in Haiti is mandatory. Human resources are the most important asset of any system and to achieve ambitious health goals, we need to maintain our precious medical work force.

Presenting my research entitled “Evaluation of antibiotics self-medication among outpatients of the State University Hospital of Port-au-Prince, Haiti” on April 2016.

 

Is Port-au-Prince’s Environment Making Us Sick?

The original version of this article is published on Woy Magazine.

A few years ago, I picked the front seat of a tap-tap heading to Pétion-ville. As usual with these common public transportation vehicles, the old car hardly moved up the hill to my destination. A couple of minutes later, a truck with the sign “O-Lavi”, selling clean water across the city, drove past.  A thick line of dark smoke coming from its muffler spread in the air and through the tap-tap which had no windows. The passengers started coughing, including the driver who had to park the car for a while because the dark smoke prevented him from seeing the road ahead.

Since then, I’ve experienced such events more and more frequently, making me wonder if Port-au-Prince’s environment is becoming a source of diseases. In fact, 12.6 million deaths linked to the environment occur annually in the world.  Many of the causes are partly due to environmental hazards identified by the World Health Organization: air pollution, community noise and poor sanitation. In Port-au-Prince, exposure to such hazards is almost unescapable. So I decided to look into how environmental factors are potentially affecting the residents of Port-au-Prince.

Air pollution

Toxic gas emissions often pollute places where most people live, since they also attend their occupations there. These emissions usually come from vehicles engines or burnt domestic wastes. For example, when vendors setup their businesses along the streets, trucks or motorcycles regularly pass or stop nearby. When the engine is started, merchants and passersby often inhale expelled gaseous components. People who travel via public transportation also inhale these while  stuck in traffic, because tap-taps and other vehicles used for Haitian public transportation are usually semi-open.

According to a study published in 2016, children from lower socio-economic households have a higher risk of specific respiratory health problems due to traffic volume and air pollution exposure. Further research found that air pollution contributes to the development of asthma throughout childhood and adolescence. Even when no specific link between air pollution and respiratory infections has been established in Haiti as of this writing, the latter is one of the most common causes of death among children. Despite these heavy potential consequences, air pollution is never a lone factor.

Community noise

Often associated with heavy traffic, community noise increases with the fast urbanization of Port-au-Prince. Business development attracts more people to the city every year and results in more and more noisy traffic jams.  In many neighborhoods, street vendors using megaphones to attract clients, churches with loud sound system, or a motorcade with roaring sirens are common occurences. In fact, the typical street scene in Port-au-Prince produces a cacophony. But the absence of a proper legislation shows the little importance attached to community noise.

In such environment, the level of stress among most people can quickly rise; especially among the poorest who tend to live in cluttered neighbourhoods. A study conducted in Ghana in 2015 revealed that occupational noise might increase the level of a stress hormone and the heart rate consequently. In my opinion, similar results can be found in Port-au-Prince. Overtime, this lifestyle might lead to a heavy burden of cardio-vascular diseases.

Poor environmental sanitation

Besides air pollution and community noise, poor sanitation is another environmental factor impeding the health of the population in Port-au-Prince. The remoteness of certain neighborhoods usually leaves little access to the city’s trash collectors. The high price of private services is often a barrier for many. So, people frequently fill the nearest gully and even the main roads with domestic wastes. When they don’t burn it, the trash remains in the communities for days. So as one goes through the streets, it is not uncommon to notice plastic bottles, used tires, or a dead animal among the wastes. Sometimes, even human feces stain the sidewalks, possibly a consequence of 6.3% of households in the metropolitan area having no toilets. The rain might easily carry away the wastes, polluting clean water sources.

The lack of a proper waste management system has made Port-au-Prince more vulnerable to the rapid spread of the cholera epidemic since 2010. It also opens doors to other diarrheal diseases- less known- affecting most children and malaria which is endemic in Haiti. Furthermore, a Zika epidemic to which poor sanitation is a vehicle is currently unfolding in Haiti, affecting thousands of people so far. Most of the people affected live in Port-au-Prince.

If we are willing to leave a healthier Haiti to the future generations, it starts with the courage to assess where we are and come together to change it for the better.

On my way back from Pétion-ville that day, the bus I rode in trudged on despite the apparent malfunctions of the engine. Along the road, people went about their daily activities with no worry about any threat. Usually, the three factors described in this article here combine to provoke the worst. But life goes on in Port-au-Prince inside the smog filled air and ambient noise, merchants lay their foods on the bare ground, among garbage and dust. This is the daily life of most of the population amidst a lack of medical services. Actually, considering the potential impacts of air pollution, community noise and poor sanitation, the environment of Port-au-Prince suggests that the population’s health is unlikely to improve in the next few years. In hopes to reverse this trend, the public health and prevention advocates must join hands with environmental activists to fight these threats. If we are willing to leave a healthier Haiti to the future generations, it starts with the courage to assess where we are and come together to change it for the better.

On the shades of violence in Haiti

When we first moved to our current neighbourhood ten years ago, the sides of our impasse was occupied by poorly maintained shrubs and houses isolated from each other. Only one car could manage to go through a narrow path left between the trees. Acquaintances often quipped about us living in such a remote place, hardly accessible and sometimes dangerous, given the numerous cases of kidnapping that had occurred there in the past. Indeed, the main avenue was not even fully concreted and huge potholes spread along the road. But ever since the earthquake hit, people from diverse and unknown backgrounds have settled on unfenced lands nearby, slowly changing the settings. Retail sale of clairin, a popular alcoholic cocktail, has flourished since then and round the clock gambling also attracts many young unemployed. Gun related and gender specific violence were quickly added to the picture, outlined by injuries, addiction and mental health issues.

Over time, we got used to the times when drunken men cause inconvenience and to the days when quarrels over money or marriage issues block access to our home. But as an extreme example of how unchecked violence has spread, three young men were recently found dead on the streets, killed by heavy gunfire heard during the night. Surprisingly when it comes to violence, young people seem to be the most vulnerable. Violence claims the lives of 200,000 young people per year worldwide and represents the 7th cause of death in Haiti.

The disastrous political context of the country during the last decades has shaped the minds towards believing that violence is inevitable. Not only have people engaged in violent acts for the smallest rewards, but many accustomed to political turmoil think of violence as a substantial part of their daily life. The general public and the policy makers consider violence more as a banal indicator or trend, going up and down but never as an issue plaguing their own personal and community health. In our communities, the trivialization of violence is in fact, the result of inaction which results in more violence, repeating a vicious cycle and accumulating into increased cases of serious injury, chronic diseases and perhaps lowered life expectancy.

The popular culture has long encouraged violence against women through apologies of machismo and the objectification of women. It goes without saying that despite women’s rights activists’ campaigns, they remain the largest target of verbal and physical violence. Misogynistic words being too often valued and praised, they somehow abound in the media, accompanied by degrading images of women and hateful mocks. Even in my youngest years growing in Cap Haitian, the tendency to disregard women and LGBT communities’ values had already been deeply rooted in most boys my age. So it was not surprising that, as a medical intern in Cap-Haitian decades later, I couldn’t keep count of the cases of gender-related violence registered in the emergency service. There were even cases where serious burns were the consequence of such domestic violence.

Besides the factors mentioned above, structural violence seems an even more important cause of physical violence. The lack of education, unemployment, social and economic inequalities, exclusion, gender-based, racial or religious discrimination and poverty among other factors stand as complex mechanisms preventing many people from defining and fully realizing themselves. In the countryside, the absence of an efficient mean to uphold justice leaves enough space for violent conflicts over land tenure, often leading to deaths. Although there are no excuses to violence, it is rooted in a highly unequal society, which leaves very little opportunities through decent jobs and an environment to realize one’s potentials. As a matter of fact, the World Health Organization referred to concentrated poverty, easy access to alcohol, drugs and guns and weak governance as main risk factors for youth violence. And as far as we know, the daily lives of most occupants of cluttered neighborhoods in Haiti consist of much of these factors.

Although the population may rejoice in the brutal murder of robbers, these acts may not be more than a Band-Aid on a deep wound, if the core problems remain unaddressed. Perhaps it would be useful to keep engaging all communities proactively in order to expel the idea that violence is normal and inevitable in Haiti. Communication should counter the idea that the situation is acceptable today simply because it was worse 12 years ago, because no level of violence is suitable. It will be mandatory, to teach or keep reminding our communities the fact that women are equal to men both in their body and their mind. School children should be taught that violence makes orphans and leads to many health consequences. If young people are offered the opportunity to play a role in their country’s path to development, if they are able to support their families with dignity and respect for others’ property, it will certainly make a difference and that is definitely a worthy investment for the future.

The weight of social approval

During a short break from seeing patients, I was sitting behind the desk, enjoying an appealing novel. In the heart of the neighborhood of Jalouzi, in Petion-ville, the atmosphere was rather comforting, punctuated with laughter of children and chants of street vendors wandering outside. Betty, the nurse in charge of patients’ vital signs laid on the wooden bench in the waiting room looking preoccupied. At some point, she got closer to me and shared her concern: Ever since she started working at the center, she had gained several pounds and feared to have crossed the line of obesity, making her susceptible to the health threats associated with it (mostly cardiovascular diseases).

Betty is a short and curvy, 24 years old woman. She confessed to never doing exercise. Even back when she was at school, the court was too small and physical education wasn’t part of the curriculum. She also grew up in a family where women proud themselves on their thickness. According to her family and peers, it is a mandatory asset to attract a mate.

Generally, clinicians use the Body Mass Index (BMI) to assess the adequacy of weight in patients. This index, designated as indicator of fatness, is a ratio of the weight (kilogram) in relation to the square of the height (meter) of the person. A BMI score equal or greater than 30 is required to classify a person as obese while between 25 and 29.9, he/she is said to be overweight. In 2008, the World Health Organization reported an increase in the number of overweight and obese people, especially in developing countries where 115 million people bear the burden of disease due to obesity. It is important to note because in developing countries, including Haiti, the many health problems co-exist with poverty and a blatant lack of basic education, strengthening the vicious circle. As a consequence, the impact of obesity goes beyond the individual and also affects the State in terms of cost of related diseases.

Betty had a BMI at 34; far along in the side of obesity. When I asked about her diet, she told me that she often consumes fried and greasy meals many times a day. Her sedentary lifestyle along with the popular culture that particularly promotes female thickness is also a factor. Other obese patients have even confessed to having resorted to self-medication and other practices to gain weight and develop a body shape, given the social standards, that is valued by most people. Bearing in mind the concept of health as defined by the World Health Organization, self-acceptance undoubtedly has an important role to play in the overall well-being of a person. But self-acceptance is sometimes too tightly dependent on social norms. Therefore isn’t it important in specific cases to question these norms and ideas of beauty that lead to self-flagellation and degradation of the body in the long term?

For instance, let’s go back to the origins of the Body Mass Index used to determine obesity. It was first described in 1832 by a Belgian mathematician and statistician called Adolf Quetelet. After the Second World War, it became crucial to develop a reliable index of normal body weight as the relation between weight and illness and death represented such a shattering concern in the medical world. But the researchers only referred to Anglo-Saxon populations to gather the data. Hence, the ideal Body Mass Index is not quite representative of the every person since African populations among other ethnics had been ignored in the studies. Another bias is that fat is not the only component of body mass. Muscle mass makes it even harder to generalize the obesity measurement standard. As a matter of fact, studies have shown that blacks have lower body fat and higher lean muscle mass than whites, so the same BMI score may lead to less obesity-related diseases. It doesn’t mean that the index per se is useless in African populations but the situation opens doors to further research which may lead to ethnic adjustments. In that vein certain groups have begun to lower cut-off points for the BMI of Asians.

After our exchange, Betty promptly acknowledged the challenge to merge her idea of beauty with her desired state of health. While the prospect of developing a perfectly objective standard for determining obesity and its health risks is still blurry, we need to keep in mind that the perception of beauty itself remains subjective. The balance between what is culturally preferred and what is healthy is also delicate and difficult to reach. Undoubtedly there seems to be a shift of consciousness among young women in Haiti. Hopefully properly designed and culturally tailored health communication campaigns are going to meet them halfway.