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.

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.


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.


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.