One morning, I went with two colleagues to Haiti’s direction of epidemiology in order to collect information for a research project. As we enjoyed some local coffee with a familiar executive at his office, he instructed us about “the good old days of disease surveillance in Haiti”. This is how he referred to the era where people from remote communities themselves reported cases of malaria to concerned authorities. They would cross through villages to identify people who were suffering from fever in their homes, he said in a melancholic tone. The past years, my research works allowed me to learn, through such anecdotes, about the systems we have set up to observe the dynamics of diseases in Haiti. While he spoke, I observed with no great surprise that the walls of the office were garnished with many US CDC (Centers for Disease Control and prevention) logos. But I couldn’t help wondering in my deeper self, how can global efforts learn from Haiti’s history of epidemiologic surveillance.
While there are many definitions for epidemiologic surveillance, the authority for this matter in the US- which is the CDC– considers it as the continuous collection of health information and their dissemination to stakeholders in order to make public health decisions. This process lies at the heart of a common commitment that some countries and institutions made in 2014, through an initiative called the Global Health Security Agenda. They work to ensure a level of preparedness to face global health threats similar to the Ebola epidemic that happened in Western Africa from 2013 until 2016. Local surveillance and global security are thus intertwined.
In Haiti, although the US military used sanitary surveys to assess the country’s situation during the 1915 occupation, a site-based surveillance system has been created only in 1990, thanks to the support of various NGOs. In fact, these organizations have been operating in Haiti since the 1950s. But soon after a coup-d’état exploded in September of that same year, the deteriorating political situation has occasioned an abrupt halt in foreign aid, crippling the public health surveillance system. Later, foreign partners supported the Haitian Institute of Childhood in relaunching the surveillance of the following conditions : malnutrition, vaccine-preventable diseases, diarrhea, acute respiratory infections and cholera.
The Direction of Epidemiology, Laboratory and Research where I was discussing with my colleagues, is now in charge of epidemiologic surveillance. The CDC and a couple of NGOs are its partners and help bring modern diagnostic tools and technologies and contribute to the training of public health professionals. The cooperation with the CDC was crucial in the aftermath of the earthquake in 2010- because many infrastructures were destroyed- and the introduction of cholera, months later. Moreover, it allows for the surveillance of polio, malaria, tuberculosis, HIV infection, respiratory diseases among other diseases and the launch of a bio-safety laboratory recently. It is worth mentioning that some NGOs run independent surveillance systems or activities whose priorities are not necessarily aligned with Haiti’s vison. From the 1990s to this day, such foreign entities have played a major role in Haiti’s epidemiologic surveillance. It has resulted in a lack of sustainability and State ownership over that matter.
This history hence raises the question of Haitian sovereignty. How can foreign actors intervene so largely in this sector ever since epidemiologic surveillance started here? Who set the priorities? How does availability of international funds affect it? In fact, with progressing globalization, sovereignty can no longer be assessed through the lenses of the past centuries world, marked by violent conquers. Some common issues call for a shared responsibility and thus comes a shared sovereignty. But such interdependency does not have to favor the donors and leave the beneficiary of aid vulnerable. It needs to respect and promote local culture, language, history and institutions. As Dr. Nahid Bhadelia put it in a tweet, “the global health security agenda is as much an insurance for the resource rich world as it is for the global south… We need to address the question of inequity in trade and how we support development of stable national governance.”
And we can’t “technicalize”/medicalize all solutions. We need to address the question of inequity in trade and how we support development of stable national governance (though US has no moral high ground on that right now!)
— Dr. Nahid Bhadelia (@BhadeliaMD) February 28, 2018
This is the ultimate lesson Haiti’s experiences of disease surveillance can bring to the current global efforts even though the country is not a member of the security agenda. While it soon passed midday, I cheerfully thanked our host at the office for his hospitality and the coffee. What I learned beyond the malaria anecdote and through the days following that conversation, is that Haiti’s epidemiologic surveillance has always been an object of foreign influence, although such entities perform on a global scale. At times, it was left vulnerable. But with respect to Haiti’s identity, the limits can be overcome for a globally healthy future.