Social Issue

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.

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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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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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Uncategorized

Resilience is resistance

Being the first black republic in history on 1804, it goes without a doubt that Haiti was born in unbearable suffering. More than two centuries later, the country’s history still holds an uncountable number of tragedies and struggles, begun with the assassination of Jean Jacques Dessalines, the founder father of the nation. To make a long story short, political instability and corruption coupled with several natural disasters have plunged the western part of the Hispaniola island in deeply rooted poverty. But contrary to popular beliefs, such conditions of existence are far from abating the people. As an example, on his visit in 2010, former France president, Nicolas Sarkozy was right to affirm that though it was bruised on a never-ending night (January 12), Haiti has remained standing. A lesson of courage to the world.

Resilience, which has nothing to do with invulnerability and social success, is the key to unveil this mystery. The french psychiatrist Boris Cyrulnik defines it as the ability to stand against all odds and pursue one’s development despite the many adverse circumstances. Resilience relies on multiple factors to grow, among which four can easily be identified in Haiti: the creole language, religion, community life and music.

A language is a powerful tool that allows you to communicate your whole person besides expressing a practical idea. In the case of creole, it is strongly tied to the Haitian’s creative mind. Through its flexibility, It offers a wide opportunity to appropriate oneself of a situation and consequently hold power over it. The Haitian humor has been well expressed in the word “goudougoudou”, based on the sound of concrete-made houses shaking during the earthquake. The word aimed to name the event but also gave the people a certain level of familiarity with the disaster and the ability to raise themselves over it. Other creole words or proverbs are as powerful such as “wozo” (reed in english) meaning that Haitians may bend over but never will they break down. However, creole is not the only factor boosting the Haitian resilience.

From the beginning, religion has played an astonishing role in the slaves’ ability to cope with their situation and to overcome it with courage and pride. The story of Bois-Caïman ceremony which led to a catastrophic revolt, testifies the importance of religious gathering through Haitian history. It was such a known fact that the French have forbidden all kind of vodoo practices in Saint-Domingue colony. But as the iconic group Boukman Eksperyans asked in “Kouman sa ta ye” song: “what would it be like, if it wasn’t for vodoo?” Until today, the majority of Haitians practice vodoo (though secretly because of cultural discrimination) along with Catholicism and Protestantism which are highly spread and constitute deep sources of hope and force for the people. No matter the confession, religion remains an unquestionable pillar for resilience building in Haiti.

Cayman wood ceremony by Ulrick Jean-Pierre

Cayman wood ceremony by Ulrick Jean-Pierre

In line with religion, community life is another big rock in the process. It is common in Haiti to assimilate neighbors to family. Activities like agriculture, religious practices, commerce and entertainment evolve around various size of more or less constant communities. Even impermanent ones play a major role, like a cheerful tap-tap or a marketplace where strangers share a portion of their life with anyone like old acquaintances . In Haiti, the communities constitute an appropriate frame necessary to nurture one’s character and contribute to his continuing development no matter life’s circumstances. In hard times, when a hurricane hits or during the post-earthquake period, when a mother, a father or a child dies, when losses are unexpected and hard to accept, having a community to rely on is already a step towards a new beginning. In brighter moments like a child-birth, a kid’s first communion or a large harvest, the community’s presence remains highly reliable.

The last growth factor for resilience we’d like to describe here is not however, the least prevalent nor important. Every second of an Haitian’s life is punctuated by music. It lives in his soul no matter the type, the more popular being konpa, rasin and creole rap. The current president himself, is a former popular singer and musician of the konpa group Sweet Micky. Music is the perfect vehicle for expressing the dreams, fear, sorrow, beauty, sarcasm, accomplishment, spirituality, political position or any common life experience. It is where Haitians look at life, grasp it, question it and make it their own. Every moment of life- carnival, protests or elections- carries a variety of rythm or definite songs. With the power of music, the most unbearable situations become poetry, a comfortable place to grow better and be more resilient. As an example, Zenglen reminds people to keep fighting despite the daily struggles in its song “Rezilta” (Results). More others can be found to illustrate the importance of music in growing resilience. This is absolutely why carnival and rara can be counted as the most popular seasons in Haiti.

This analysis of the four different elements cited above, under the light of Haitian history and daily life events, has let us trace down their impact on character building, on the way they help people turn tragic events into relatively harmless memories and definitely how they contribute to development of constant resilience in Haiti since centuries. This core attitude is critical to the existence of Haitians as a people. Resilience is their resistance. Resistance against inertia, defeat, resignation and mind slavery. As the Haitian proverb goes: “Toutan tèt pa koupe, li espere mete chapo” (As long as the head is not cut off, there’s hope to wear hats). Day by day and one stone at a time, Haiti will strive to keep building its resilience castle.

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HIV/AIDS, Public Health

HIV/AIDS and Discrimination: A wrestling history

wrestling

As I was completing a two month internship in Brussels, I surprisingly noticed that my coworkers knew little to none about Haiti and its troublesome yet tremendous history. Their rare assertions turned around the political instability and discriminating facts pertaining to the HIV/AIDS epidemic evolving in the country since at least three decades. As a matter of fact, the HIV virus (isolated by Robert Gallo and Luc Montagnier in 1983) has originated in West Africa and spread to humans since the early 20th century. Since the very first years of this 30 years-old pandemic, discriminating ideas have travelled the world and survived until today, even among the most academically educated people. Looking at the history of the deadly disease, I’ve come to realize how the fight against social and ethnic discrimination has led to outstanding progress towards a better future.

The year 1981 marked an astonishing turning point in human history. On June 5 of that year, the Centers for Disease Control and prevention (CDC) published a report of five cases of a rare lung infection known as Pneumocystis carini pneumonia (PCP) among gay men in Los Angeles, USA. In New York and California, cases of a rare cancer, Kaposi’s sarcoma, were also reported to the CDC in the same period, leading to a total of 270 cases in the USA, by the end of the year. The general press prompltly used the terms “gay related immune deficiency” and “gay cancer” to describe the new disease and suggest a link between homosexuality and the disease.

On 1982, among the cases reported to the CDC, 34 were Haitians residing in the USA and eleven in Haiti. This discovery has led the CDC to conclude that being Haitian was a separate risk-factor for the newly spread disease and coined the term “4H disease” to point out male homosexual, heroin users, hemophiliacs and Haitians as at-risk groups. With such a denomination, it was the beginning of an unprecedented discrimination era based on sexual orientation and ethnicity. In a study published in 2010, it is stated that the HIV discrimination against Haitians resulted in the devastation of Haiti’s fragile economy.

The discrimination had serious consequences in regards to the spread of the disease. People with symptoms suggestive of the newly identified syndrome lived by fear of rejection, quarantine or violence. Until today, discrimination remains a challenge when it comes to treating the disease. It is a common factor contributing to delayed treatment in HIV cases, even in developed countries. It also impairs the public health strategies dedicated to test at-risk populations and control the epidemic. Therefore, the fight against AIDS has always been tightly linked to the fight of discrimination. At the time of “4H disease” there was a social, cultural and scientific (because of a poor understanding of the new syndrome) barrier which threatened the proper management of the epidemic.

100.000 Haitians protested in NY against FDA policy on blood donation Photo credit: @carelpedre twitter account. April 20, 2015 @ 7:55 AM

100.000 Haitians protested in NY against FDA policy on blood donation
Photo credit: @carelpedre twitter account. April 20, 2015 @ 7:55 AM

In this context, an unexpected event happened in the United States. On 1983, a New York doctor was threatened with eviction from his building for treating HIV patients. It led the Lambda legal group and Gay Men’s Health Crisis to file and win the first AIDS discrimination lawsuit in the USA. And, in July, the U.S. Congress enacted the Americans with Disabilities Act (ADA) which prohibits discrimination against individuals with disabilities, including people living with HIV/AIDS. Even though discrimination against gay communities persists today, this was a shining light spread upon the entire world regarding the necessity of banning stigma.

Years later, in New York, home of the largest Haitian diaspora community, 100.000 Haitians assembled and marched on April 20, 1990 in protest against a decision of the CDC forbidding Haitians and sub-Saharan people to donate their blood to blood banks. As reported by the New York times, Dr. Jean Claude Compas, said, “This policy is on the basis that Haitian blood is dirty, that it is all infected with the HIV virus. The decision is based not on sexual preferences, but on nationality, ethnicity.” Placards mentioned: “We’re proud of our blood,” and, “Let’s fight AIDS, not nationality.” Following this protest, a Food and Drug Administration (FDA) advisory committee voted to urge the CDC to abandon their policy based on exclusion.

100.000 protesting in NY against FDA policy on blood donation Photo credit: @carelpedre twitter account. April 20, 2015 @ 7:55 AM

100.000 protesting in NY against FDA policy on blood donation
Photo credit: @carelpedre twitter account. April 20, 2015 @ 7:55 AM

There is no doubt that in every corner of the world, discrimination against HIV infected people of any social category and ethnicity has been fought with vigor. In the light of the essential principles which guide humanity, AIDS is regarded today as a chronic disease and infected people ought to be cared for with the utmost dignity. To repeat the words of Ambassador Deborah L. Birx, “We won’t see an end to the epidemic as long as people living with HIV/AIDS feel unsafe and are forced to the fringes of their communities” The two major events described in this article have helped the world acknowledge how critical the battle for human rights has been in insuring a better future for all. Haiti is experiencing a declining prevalence since 1990. In this era of globalization, it can only be great news for the world. But this success is fragile and our common effort is required to sustain it. Share this paper in order to raise awareness on the need for inclusion and respect of all human rights no matter their health status.

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Public Health

WHY YOUNG DOCTORS LEAVE HAITI

This article was originally posted on Woy Magazine

Despite the many efforts of the health ministry and its partners, the Haitian sanitary landscape is plagued by chronic and infectious diseases and trauma. Half of the country’s population suffers from hypertension (EMMUS V) , and four years ago, a major cholera outbreak erupted killing thousands of people. Unfortunately, the level of sanitary education in the Haitian population remains among the lowest. These factors, coupled with some of the worst conditions in the northern hemisphere contribute to the 61-64 year life expectancy (EMMUS V). In the midst of this catastrophic public health state, a staggering number of physicians leave Haiti year after year, further exacerbating the 2 doctors for 10,000 inhabitants ratio. Why is Haiti’s health sector experiencing such an exodus? This article’s aim is not to exhaustively analyze all of the reasons why Haitian physicians leave, but to discuss the reasons I  have observed among my peers.

Poor financial reward

A licensed doctor- either a general practitioner or a specialist- employed by a state health care institution, earns around 32,000 HT gourdes a month. This is the equivalent of US $7,384.61 a year, according to the national bank exchange rate. While some doctors run private clinics, it is not uncommon for many to work for more than one institution in order to earn a decent living. In this field, as in any other in Haiti, it is difficult to secure a good job, and clinics bring less and less income because people lack the means to pay private doctors. It should be noted though, that some doctors who own private practices are very successful.

Let us dare a comparison: In France, the average net salary of a general doctor is € 6, 664 a month (UNASA, 2012); which is the equivalent of US $103,958.4 a year (€ 1 = US $ 1.3 in april 2012). As Atul Gawande stated in his book Better: A surgeon’s notes on performance, in 2003, the median income for primary care physicians in the USA was $ 156,902, and for general surgeons, it was $ 264,375. Active orthopedic surgeons, cardiologists, pain specialists, oncologists, neurologists, hand surgeons and radiologists frequently earn more than half a million dollars a year.

Inappropriate work environment

In addition to the poor financial reward of practicing medicine in Haiti, the work environment is not ideal. When it comes to the health care system, one can easily notice a significant difference between reality and what is reported. Poor governance by the ministry of health has led to a residency fiasco, where a group of state students have used intimidation and false propaganda to make the ministry withdraw previously held fair policies. The programs themselves are poorly run in terms of leadership and mentoring. A lack of proper andragogy plagues the tutoring program, and fear and brutality are frequently used teaching methods. Therefore, the results are far from what is expected; the physician, who is supposed to be the kindest human being, tends to lose his/her humanity in such a situation. This sense of humanity is also slapped on a daily basis by the uncleanliness and the unpleasant odor of the work place

The health care system is broken in so many ways, it seems like we do not have the necessary administrators to fix it. The eternal war between public and private medical schools can prove this fact. As a result of the weaknesses of the system, the hospitals lack even the basic materials like sheets for the beds, gloves for doctors and nurses and sterilized equipment. Often, the materials available are so outdated; they can not be properly used to save a life in a matter of minutes.

Examination room of a community health center at Jalouzi, Port-au-prince

Examination room of a community health center at Jalouzi, Port-au-prince

Lack of continuing education opportunities

For the doctor, education does not stop the last day of medical school or residency program. Practicing medicine is a lifetime commitment to study and research. It would be unfair not to acknowledge the efforts of the health ministry to provide Continuing Medical Education in Haiti. But again we are faced with the inequity issue, as these opportunities are not available for every doctor. In fact, not enough resources, mainly live events, are available for the number of physicians requiring such initiatives in Haiti. In the USA, the American Medical Association has gathered resources to help physicians meet their professional goals. These resources include things such as: live events, written publications, online programs, audio, video, or other electronic media.

Lack of Confidence

Haitian doctors are aware of the worldwide situation of the medical science. Thanks to globalization, foreign doctors can personally engage with doctors in Haiti and vice-versa, to learn from each other and improve their skills and medicine in general. On such occasions, a feeling of low self-esteem seems to conquer too often the minds of even well trained Haitian doctors. As a consequence of the previous flaws described, there is a feeling of shame that adds to the burden. The lack of confidence makes many Haitian doctors doubt their skills. As one stated in a conversation: “… [I would] rather be a good nurse in the USA or Canada instead of being an unqualified doctor in Haiti.” While Haitian doctors have shown impressive skill and judgment no matter how poor the work setting, low self-esteem remains a poison.

How is it possible that our basic conditions are so unsatisfying? Over the years, I have realized that arrogance, greed and incompetence are given the priority over what truly matters. Politicians only care about their own agenda instead of the health of the people. Therefore, bad governance leads to such unresolved crises. The status quo is guarded by people who are in position of power as long as it is profitable for them. Exclusion is then the norm. We must tackle all of these issues to prevent this massive exodus of young Haitian doctors.

I personally work with people who dream to become cardiac surgeons, army surgeons, health system designers, health care entrepreneurs, world-class professors, genetic researchers and more. I work every day with people who are motivated to pursue and conquer their dreams. The ambition is palpable. But where in Haiti can a doctor receive such training? How can a Haitian doctor lead such a fruitful career without eventually leaving one day?

Let me be clear, I do not wish to judge the quality of medical training in Haiti. I do not have the competence required to do so. This is what I do know, doctors who refuse to settle for the Haitian system are searching for an inclusive system, better work environments, open opportunities to learn more and greater financial reward. Correct me If I’m wrong, in any well-functioning society, these factors are any professional’s most basic rights.

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