Global Health, HIV/AIDS, Public Health

Disease Surveillance: Lesson From Haiti

One morning, I went with two colleagues to Haiti’s direction of epidemiology in order to collect information for a research project. As we enjoyed some local coffee with a familiar executive at his office, he instructed us about “the good old days of disease surveillance in Haiti”. This is how he referred to the era where people from remote communities themselves reported cases of malaria to concerned authorities. They would cross through villages to identify people who were suffering from fever in their homes, he said in a melancholic tone. The past years, my research works allowed me to learn, through such anecdotes, about the systems we have set up to observe the dynamics of diseases in Haiti. While he spoke, I observed with no great surprise that the walls of the office were garnished with many US CDC (Centers for Disease Control and prevention) logos. But I couldn’t help wondering in my deeper self, how can global efforts learn from Haiti’s history of epidemiologic surveillance.

While there are many definitions for epidemiologic surveillance, the authority for this matter in the US- which is the CDC– considers it as the continuous collection of health information and their dissemination to stakeholders in order to make public health decisions. This process lies at the heart of a common commitment that some countries and institutions made in 2014, through an initiative called the Global Health Security Agenda. They work to ensure a level of preparedness to face global health threats similar to the Ebola epidemic that happened in Western Africa from 2013 until 2016. Local surveillance and global security are thus intertwined.

In Haiti, although the US military used sanitary surveys to assess the country’s situation during the 1915 occupation, a site-based surveillance system has been created only in 1990, thanks to the support of various NGOs. In fact, these organizations have been operating in Haiti since the 1950s. But soon after a coup-d’état exploded in September of that same year, the deteriorating political situation has occasioned an abrupt halt in foreign aid, crippling the public health surveillance system. Later, foreign partners supported the Haitian Institute of Childhood in relaunching the surveillance of the following conditions : malnutrition, vaccine-preventable diseases, diarrhea, acute respiratory infections and cholera.

The Direction of Epidemiology, Laboratory and Research where I was discussing with my colleagues, is now in charge of epidemiologic surveillance. The CDC and a couple of NGOs are its partners and help bring modern diagnostic tools and technologies and contribute to the training of public health professionals. The cooperation with the CDC was crucial in the aftermath of the earthquake in 2010- because many infrastructures were destroyed- and the introduction of cholera, months later. Moreover, it allows for the surveillance of polio, malaria, tuberculosis, HIV infection, respiratory diseases among other diseases and the launch of a bio-safety laboratory recently. It is worth mentioning that some NGOs run independent surveillance systems or activities whose priorities are not necessarily aligned with Haiti’s vison. From the 1990s to this day, such foreign entities have played a major role in Haiti’s epidemiologic surveillance. It has resulted in a lack of sustainability and State ownership over that matter.

This history hence raises the question of Haitian sovereignty. How can foreign actors intervene so largely in this sector ever since epidemiologic surveillance started here? Who set the priorities? How does availability of international funds affect it? In fact, with progressing globalization, sovereignty can no longer be assessed through the lenses of the past centuries world, marked by violent conquers. Some common issues call for a shared responsibility and thus comes a shared sovereignty. But such interdependency does not have to favor the donors and leave the beneficiary of aid vulnerable. It needs to respect and promote local culture, language, history and institutions. As Dr. Nahid Bhadelia put it in a tweet, “the global health security agenda is as much an insurance for the resource rich world as it is for the global south… We need to address the question of inequity in trade and how we support development of stable national governance.”

This is the ultimate lesson Haiti’s experiences of disease surveillance can bring to the current global efforts even though the country is not a member of the security agenda. While it soon passed midday, I cheerfully thanked our host at the office for his hospitality and the coffee. What I learned beyond the malaria anecdote and through the days following that conversation, is that Haiti’s epidemiologic surveillance has always been an object of foreign influence, although such entities perform on a global scale. At times, it was left vulnerable. But with respect to Haiti’s identity, the limits can be overcome for a globally healthy future.

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Public Health

How January 12 reopened the conversation on Haiti’s healthcare system

A typical January morning in Haiti, the 12th of the year 2010 greeted a bright sun and the usual bustle of the island life. While the majority of schools and churches were functioning as usual, traders crowded the pavements, carelessly dealing with their routine. Hope warmed up the hearts of the Port-au-Prince population, following the sweet Christmas of 2009 whose memories were still fresh. But on this day, a magnitude 7 earthquake was registered as a painful page in the life of the people, definitely changing the course of history by taking the lives of hundreds of thousands of Haitians. Countless people have suffered serious injuries, including those who have seen their mobility limited overnight or the ones amputated one or more members in order to survive. In all minds, fissures are still present today either as post-traumatic shock disorder or severe depression. Since then, new sets of questions have punctuated our daily lives, especially related to our way of embracing the future. This catastrophic event opened the way for new conversations about the Haitian health system. Words and ideas are far from exhaustion as the wounds are still slow to heal.

In March 2011, one year after the unfortunate event, Dr Jean Hugues Henrys, current Dean of the Faculty of Medicine of the University Notre Dame of Haiti, gave a speech at the Bloomberg School of Public Health. Through the course of his lecture, he has drawn the profile of the existing Haitian health system before the earthquake, compared to a set of decentralized health microsystem, in transition between infectious and chronic diseases. In the aftermath of the disaster, it was imperative to adapt according to Dr Henrys, because the many amputees were considered a priority, while hardly enough resources were available to support them. He also emphasized the urgent need to provide mental health services to the people while the subject was sparsely considered in the past, forsaking many to discrimination and stigma. This has revealed the lack of disaster preparedness that existed in the healthcare system on many levels: logistics, human resources and education.

For Dr Henrys, a partnership between public and private institutions would contribute to ensure a better future. Inaugurated two years after the earthquake, the university hospital of Mirebalais born of the partnership between the Ministry of Health and Partners In Health (US-based NGO operating in Haiti), treats patients through its various services and largely contributes to educate the new generations of nurses and Haitian doctors. It is among other projects that have emerged in an effort to better equip the country with capabilities to respond to eventual catastrophes seen as a constant risk.

But the lack of preparedness which patients were the victim following the January 12 concerned not only the psychological and medical care themselves but went well beyond. The Haitian health system was evolving in a chaotic situation and also deserved attention. The fear of a “phantom epidemic” of diphtheria fueled the minds for weeks following the disaster while a true epidemic was unlikely and coordination between NGOs was poor. In an article published in 2013 entitled “The celebrity as Hero: When Sean Penn has Fought Phantom Epidemic“, the American journalist Jonathan Katz counted the panic caused by the death of Oriel, aged 15 years, blaming the lack of a competent system which the teen’s parents could have used days earlier. The infrastructures already shaky before the earthquake, had completely disappeared on January 12, leaving the country in the most complete desolation when a cholera epidemic erupted by the end of the year 2010. More than infrastructural and organizational issues have been raised in the debate around the Haitian healthcare system after the earthquake.

Talea Miller quoted in her article “Haiti’s Health Care System Faces a Defining Moment” published in June 2010; Minister Alex Larsen said that the state of New York has more Haitian doctors than Haiti itself. While the exodus of health workers already afflicted the health system before the earthquake, it worsened after January 12 following numerous personal losses and the deaths of many doctors and nurses whose proportion in number was highest in Port -at-Prince. This chronic haemorrhage of medical staff also nourished the debate around the health system. With only 3.5 health professionals for 100,000 inhabitants, Haiti lies behind the standards stated by the World Health Organization. Paradoxically, the broken state of the Haitian healthcare system drives away its most important assets, while they are needed to fix it.

As reported by Talea Miller, Dr Larsen believed that human resources were more important than physical infrastructures in the wake of the earthquake and advocated the benefits of conjoined educational programs between Haitian and foreign universities. Since 2010, volunteer medical teams from the United States and Canada regularly participate in mission trips at the Hospital Bernard Mevs at Port-au-Prince and largely benefit the healthcare system in terms of services and education of emergency care physicians and pediatricians.

Six years after the earthquake, the Ministry of Public Health still faces much trouble in order to pursue its core mission. One of the major difficulties lies in the financing of the system. Despite their meager resources, the households finance 96% of their health needs in spite of the minimum package of services offered by the state. We must recall that the budget allocated to the health sector does not exceed 6% of the national budget. Regardless, new structures and programs are emerging across the country, primarily financed by donor countries. But in spite of this, health indicators remain alarming and the system statistically inefficient. At a conference on health financing in 2014, Dr. Jean Alfred Patrick mentioned that there is a weakness in the regulation and coordination of health financing systems in Haiti. In other words, bad governance plagues any sustainable progress in the health sector. Instead of motivating more Haitian doctors, this context contributes to push them towards immigration.

Today, January 12, 2016, as the Haitian people commemorate the lives of the earthquake victims, they consider the path already travelled and the long road ahead. Over the past 6 years, they have discussed on many platforms the best ways to redirect the public health priorities and goals, increase capabilities in disaster preparedness, enhance the mental health of citizens, reconstruct the many destroyed health facilities, retain qualified health professionals and promote good governance in the healthcare system. From the debates, tangible solutions have been considered and implemented. And as long as the conversations keep going, there’s hope that Haitian lives will stand on unshakable ground.

candles

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