Cholera, Global Health, Public health concern

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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Cholera, Global Health, Public Health, Public health concern

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.

 

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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.

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Public health concern

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.

Paradigm shift

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Global Health, Public health concern, Social Issue

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.

Cluttered neighborhood

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Public health concern, Social Issue

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.

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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.

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Global Health, Public Health, Public health concern

Health communication in the time of Zika in Haiti

The day was coming to its end as I was dealing with annoying paperwork at an outpatient clinic in the area of Delmas, in Port-au-Prince. The attending nurse sharply knocked at the door and introduced me to Zoune, a woman in her mid-forties. Calmed by the fan in motion, the ambient heat hardly bothered on this particular afternoon. Even though January hasn’t seen any rain yet, puddles and piles of rubbish in the streets form a sure cottage for mosquitoes. The tropical temperature also stimulates their reproduction. Zoune presented clinical features of the Zika disease, urging me to initiate a symptomatic treatment based on my judgment and order a few screening tests. Ever since the confirmation of Zika cases in Haiti by the Health Department (and even before) the public carefully monitor themselves for signs of the disease and inquire with their doctor. Of course some prefer to get themselves treated with simple non-pharmaceutical interventions.

The Zika virus disease is transmitted by the bite of Aedes mosquitoes, infected by the virus. Identified in humans for the first time in 1952 in Uganda and Tanzania (Emerging point of Chikungunya virus which caused an outbreak in Haiti in 2014), it spreads especially in Africa and tropical countries. This non-fatal disease involves a febrile syndrome associated with lumbago (pain in the lower back), simulating Chikungunya or malaria which is endemic in Haiti. The emergence of Zika virus disease was foretold long before its introduction in Haiti. Climatic conditions punctuated by global warming as well as migration have positively contributed to its emergence.

Currently, one can refer to an epidemic in Haiti since Zika was simply non-existent across the territory. Even though it’s relatively simple to limit its spread- provided that hygiene and sanitation measures are met- difficulties particularly arise on this level. How to involve most of the people in this dynamic? Proactive communication is the first step in management of an epidemic. But between the limited resources and the outright flaws in the Haitian healthcare system, the public is far from being reassured. Communication weaknesses have already started to plague the good management of this outbreak, hence affecting trust even more. As a matter of fact, the confirmation notice of the presence of the disease in Haiti came late compared to expectations of the people who observed that it was rapidly gaining ground and awaited a word from the Ministry of Health.

According to my observations, the greatest fear of the public lies in the eventual complications of the Zika virus disease; mainly brain malformation in newborns and Guillain Barre Syndrome which causes paralysis of the body. Although scientific literature hasn’t confirmed any link between these complications and Zika yet, in some countries where Zika spreads, women are warned to delay pregnancy or to avoid areas affected by outbreaks. In the United States, the Centers for Disease Control and Prevention have elaborated guidelines for the screening of pregnant women by gynecologists. Some see this as a unique opportunity to revive the debate on abortion in countries where a modern law is lacking. But at the time of writing, no campaign whatsoever is officially launched in Haiti thus, no warning regarding pregnancy or increased promotion of contraception services has been issued by the Health Department. The public is therefore facing the fear of this epidemic with the feeling of being on their own.

In order to foster behavioral changes necessary to protect lives, it’s important to know the perceptions and existing practices of the population. A never-ending conversation with the public allows effective management and is worth more than sparse and scant monologues in times of panic. During the Chikungunya outbreak in 2014, the organization I co-founded integrAction was delighted to share ideas and experiences with the socio-medical staff of the Haitian Red-Cross (many of whom were infected) in Cap-Haitian during a conference. This initiative helped the organization conceive groundbreaking campaign with appropriate health communication to raise awareness via social media on the disease and the means to cope with it.

On a broader scale, the current turn of public health history is an opportunity to consider reinforcing leadership capacities from the bottom to the top, while investing in research and improving the public’s health literacy. For most of the population, there’s more fear than harm as in the case of Zoune. So engaging the people through proactive communication followed by prompt action is one of the best ways to halt the spread of Zika and its potential consequences. As they express much disappointment, the Haitian people can only hope for less vulnerability. But if today’s duties are unceasingly postponed, the future, undoubtedly, can only be more grim.

A health worker fumigates the Altos del Cerro neighbourhood as part of preventive measures against the Zika virus and other mosquito-borne diseases in Soyapango, El Salvador

A health worker fumigates the Altos del Cerro neighbourhood as part of preventive measures against the Zika virus and other mosquito-borne diseases in Soyapango, El Salvador January 21, 2016. REUTERS/Jose Cabezas

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Public Health, Public health concern, Social Issue

Let’s change the rules to save women’s lives in Haiti

Fairly called Poto Mitan in Haitian Creole, women account for 50.49% of the Haitian population and represent the center pillar of most households. From commerce to education, their contributions to the society are undeniable. As the prosperity of the nation relies on its citizen’s well-being, it is no surprise that women’s health is a public health priority when it comes to the national health policies. But despite the efforts, unsafe abortion remains unfortunately a scourge as prevalent as poorly addressed.

I recall my last shift at Chancerelles’ maternity ward where a 16 year-old pregnant girl presented with intense abdominal pain and massive vaginal bleeding. At first, she did not admit any medication ingestion prior to the onset of her symptoms. But as we pursue the medical investigations, her 30-year-old boyfriend confessed that he had provided her with 4 pills of an over-the-counter drug known to provoke abortion in pregnant women. For the gynecology residents, it was a routine and classic case. Yet openly discussing unsafe arrest of pregnancy in Haiti is controversial since it’s so much of a taboo.

The World Health Organization (WHO) defines unsafe abortion as a procedure for terminating a pregnancy performed by persons lacking the necessary skills or in an environment not in conformity with minimal medical standards, or both. Every year, 50.000 women, mostly from Latin America and Caribbean countries, die from consequences of unsafe abortion. According to the article 262 of the Haitian penal code, induced abortion no matter where or who performs it, is a criminal act and legally punished nationwide. But regardless of the law (or maybe because of it), complications of clandestine abortions are common motives of visit in general and obstetrical care facilities.

SDG3

Target: By 2030, ensure universal access to sexual and reproductive health-care services.

Carole, the latest patient I examined, was going through her second abortion experience and presented with severe anemia after 15 days of bleeding. When she got pregnant, economic difficulties arose, urging her to take the decision with her husband’s consent. But the specialized hospital she visited wouldn’t provide the desired services as forbidden by the law. So she turned to a clandestine clinic, even when the fees were high. As we shared our opinions, she said that it would be beneficial for women to abort safely with optimal medical assistance because the absence of a legal framework for safe abortion and technical capacities almost took her life away.

A few days later an obstetrician and HIV care specialist told me that to alter the perilous consequences of unsafe abortion in Haiti, it would be best to decriminalize it. Among the 530 women deaths per 100.000 inhabitants per year in Haiti, 120 are attributed to unsafe abortion. Fortunately, in the last quinquennium, the Ministry of Health has debated the subject and elaborated a new bill with several social groups to allow abortion for medical purpose and in rape cases. This is one step forward in the modernization of women’s health in Haiti even when it hasn’t reach the parliament yet.

But the main causes of induced abortion being socio-economic status, maybe the bill should also include women who desire to arrest their pregnancy for any reason other than congenital malformations or rape. It would be better if every woman could openly  discuss it with their doctors.

Because it is the State’s duty to guarantee optimal health care to the population, and health is not restricted to the body. It includes mental and social well being.

It would be valuable to couple activism with effective health communication. Because often, the barriers to improving women’s health in Haiti are some erroneous traditional beliefs. My intention here is not to downplay any religious or cultural values, as some have actually improved women’s health. My advocacy is to conduct proper scientific studies on this public health issue and clearly communicate the best ways to prevent the consequences. After all, prevention costs exponentially less than complication management and as the recently published statistics show, the State’s funds have long been depleted.

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