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The Health of Children in Haiti: Facing socio-economic realities
September 2001

by: Dr. Frantz Large, Ophthalmologist and Chief Editor, Bulletin of the Haitian Medical Association

This briefing has been produced in collaboration and with the financial support of Plan Haiti, in the scope of the project "Child Rights and Participatory Media in Civil Society."

Plan's vision is of a world in which all children realise their full potential in societies which respect people's rights and dignities.

Plan seeks to strengthen the capacity of families and communities to provide their children with stability, protection and security while improving their quality of life and advancing their rights.

The health of children in Haiti is a major challenge as 40% of its inhabitants is less than 15 years old (among which approximately 15% is under 5 years). In 2001, the population is being estimated at 8 million. 69% of medical examinations involve children under 5 years and 10% newborns (less than one month old).(¹)

In addition to the human and emotional dimensions of a child's sickness or death, or the special care required by a handicapped child, parents face heavy economic burdens in purchasing or acquiring basic drugs, hours lost in search of proper care, as well as, in a country that devotes a great respect to its dead, the cost of funerals.

An infant mortality with an uncertain direction, but certainly very high

In Haiti, the mortality rate of infants (less than 1 year old) is generally estimated at 74 ‰ according to the EMMUS II report of 1995. (²) This figure, already pathetic since it is well-above the average of Latin America (37 ‰ in 1995) as well as the figures for all the countries of the region (See Table 1), is nevertheless below the 80 ‰ given in the latest report of EMMUS (EMMUS III – 2000). (³)

Table 1: Rate (‰) of infant mortality (less than one year old) in the Caribbean region – 1999. The State of the World's Children 2001, United Nations Children's Fund.

Every year in Haiti 138,000 children under 5 years old die and 60% of those who survive do not develop well. 40% of all deaths in the Haitian State University Hospital (HUEH) occur in the Paediatric section, according to a report published by the Ministry of Public Health and Population (MSPP) in March 2000. (⁴)

"Infant mortality was underestimated in the 1995 report, which was at that time in the order of 100‰. There is actually an improvement in the figures, both with regard to infant and juvenile mortality rates," Dr. Michel Cayemites says, Director of the Haitian Institute of Childhood. (See Table 2).

What kills and what makes children sick in Haiti?

The causes of infant mortality and morbidity vary with age. Under babies between 0 and 3 months old in the intensive care unit of the HUEH paediatrics section, maternal-fetal blood poisoning infections seem to be prevalent, followed by pneumonia. There is a strong link between infant mortality and premature birth, which represents 12% of admissions.5 There is also a link between early pregnancy and premature birth, which partially explains the increased death rate surveyed under children whose mothers are less than 19 years old as revealed by the EMMUS II and III reports.

Table 2: Infant Mortality (less than one year old), Juvenile Mortality (1-4year old) and Infant-Juvenile Mortality (0-4 years old). A report over a 5 year-term prior to the survey, EMMUS III, Haiti 2000. The three major causes of mortality of children under five years old are diarrhea, malnutrition and acute respiratory infections. In addition, malaria is always there, measles, neonatal tetanus (though in great decline), tuberculosis and more and more HIV/AIDS.

It should be noted that these causes of mortality are also important causes of morbidity. On the other hand, if certain ailments do not cause the death of children - such as parasitic disorders, psychological disorders, and sensorial disorders - they nevertheless impede their growth considerably.

Diarrhea : a constant threat, but a little better treated

Diarrhea, often worsened by malnutrition, counts for 19% of the deaths recorded among children. (⁶) In children under five years, 26% had at least one episode of diarrhea during the two weeks prior to being surveyed. This figure is not incompatible with the result of previous surveys conducted in Cite Soleil (16 to 36%), as described by EMMUS III.

It is worth noting that the oral re-hydration technique, largely introduced in Haiti by Pharval Laboratories and of which 40.6% of mothers say they have used it (EMMUS III), has enormously influenced the spectacular decline in infant mortality, from 177 ‰ in 1977 to 80 ‰ nowadays.

Malnutrition : the Gordian Knot

Thirty-three percent (33%) of the Haitian population suffers from chronic malnutrition, against 2% in the Dominican Republic, 3% in Honduras and 6% in Guatemala. Eight percent (8%) of Haitians is seriously malnourished. (⁶) Malnutrition highly aggravates the number of infants affected by diarrhea, acute respiratory infections and / or infectious diseases.

Malnutrition is also a factor of morbidity, since it brings about deficiencies in the child, both intellectual and physical. For example, in the Artibonite region, which nevertheless is the breadbasket of the country, 30% of the children under one year and 61% of those between 1 and 4 years are too light for their age.

Port-au-Prince is the city which is least affected by malnutrition. Nevertheless, more than 50% of its children are too small for their age. This percentage is 65% in the Central Department.

"Being a social problem, malnutrition will only disappear through a restructuring of the socio-economic conditions of the Haitian people, as well as through the equitable distribution of national resources," the late Dr. Ary Bordes insisted.

At the first place: Acute Respiratory Infections

At HUEH, acute respiratory infections (ARI) constitute the first cause of admittance (26% of the cases of newborns aged from 0 to 28 days, 36% of those from 1 month to 1 year old and 37% of those from 1 to 5 years old). ARI represent one quart of the deaths among children under 5 years. Out of five pneumonia cases recorded at HUEH, four involve children under 5 years.(⁵)

The work by a research group on the Haitian-Dominican border reveal that acute respiratory infections represent the most frequent cause of morbidity, regardless of age group.

There is a clear link between ARI and the "crowding" (overpopulation) which characterizes housing of both the rural and urban people in Haiti, Dr. Françoise Ponticq said.

"The dominant place of acute respiratory infections in infant mortality is possibly due to the cost of treatment, which is much higher than that of diarrhea," Doctor Duc says, Director of Sanitation at MSPP/Western department.

The minimum cost of treatment of ARI with oxygen-therapy is 4,000.00 Gourdes (rate of exchange in September 2001: 24 Gourdes = 1 US$), according to Dr Jean Joseph Regis, a paediatrician in private practice, but who has worked for a long time at the Adventist Hospital.

Typhoid, measles, malaria, poliomyelitis, neonatal tetanus: slow to disappear

Being directly associated to non-potable water and the poor conditions of hygiene, typhoid represents the fifth cause of admission to the HUEH paediatrics unit: 675 cases were recorded over a one year period.

37% of malaria cases are children and each year 800 children die of this disease.

Unfortunately, measles represent also a major cause of mortality and morbidity in Haiti. Its mortality rate varies between 3.7% and 5.4% among children under five years. Because it enhances deficiency in vitamin A, measles also constitutes an important cause of blindness.

Just till last year, poliomyelitis was considered to be virtually eliminated. On 9 May 2001, however, the Minister of Public Health, Dr. Henri Claude Voltaire, stated officially that there is a renewed outbreak of this scourge, and started a national vaccination campaign to stem it.

Neonatal tetanus has declined over recent years but still persists in the rural areas where a high number of pregnant women do not receive any medical and paramedical attention, according to Dr Gerard Delys, a doctor who practices in Grand-Goave.

Tuberculosis: the strategy must be adapted to the environment

At national level, there is a prevalence of 0.5% of tuberculosis. Among this group, 11% are children from 0 to 14 years.

In 1951, MSPP created a national office to combat tuberculosis. In 1967, Grace Children's Hospital/International Child Care was established to care for children with tuberculosis between 0 and 12 years. Later on, this hospital started testing and treating people who live under the same roof as children affected by the disease.

In 1975, International Child Care created the Anti-Tuberculosis Crusade (CAT) to carry out massive BCG vaccination campaigns, focussed on the age group 0-15 years. CAT had the responsibility of anti-tuberculosis intervention in the country until 1989.

From a classic regime of twelve months, the treatment of tuberculosis is now down to a six months period. But this period has been stretched out to eight months, following a recommendation by a mixed WHO/World Bank mission, conducted in January 1997.

Contrary to the six months regime, which requires the direct supervision of the taking of drugs during the entire treatment period, the 8 months regime only requires a supervision during the first two months. "This decision reflects one of the major problems faced by a Haitian: the abandoning of the treatment," Dr. Jacqueline Gautier says, President of the Haitian Society of Paediatrics and Director of the Bon Samaritain Hospital, which main focus is children affected by tuberculosis.

One of the major problems posed by tuberculosis is its association with HIV/AIDS. In 1996, 14% of hospitalized children and 18% of ambulatory children affected by tuberculosis also had HIV/AIDS (PAHO/WHO).

HIV/AIDS : children pay the consequences

Three to five percent of the rural population and 7 to 10% of the urban population are infected by HIV. In 1998, 8.4% of tested pregnant women had HIV.(⁷) The rate of transmission during birth is about 30%. In September 1998, there were about 190,000 HIV/AIDS orphans. The number of children having one seropositive parent is much higher than the number of current orphans, according to UNAIDS.

Less than one out of three single people admits to having used a condom during the last sexual intercourse, states EMMUS III. Unlike the urban environment, in rural areas there is a very limited awareness on how to protect oneself against HIV/AIDS. Among street children, 62% never use a means of protection, Martine Bernier and Paul Ascencio state in their book: "AIDS and the children of Haiti." The near-totality of street girls practice prostitution.(⁸)

There are many prevention programmes on sexually transmitted infections, among which HIV/AIDS. Free screening of the virus is now available in many regions of the country.

When psychology is added to the drama

"Phobias can be really paralysing and be associated to depression. One special case was one of a young boy around 7 years old who suffered from insomnia, lack of appetite and lack of adjustment at school. He was notably fading away. His problem was linked to fear that his mother, who died a few months before, would come for him because of too much love," Dr. Legrand Bijoux recounts in his book "Summary of Haitian psychiatry."

"Nothing never really happens in Haitian life without the supernatural being mingled in at its highest level," the psychiatrist concludes.

Blindness and school efficiency

Among the 80,000 blind of Haiti, 15,000 or more are children. 12,000 of these are of pre-school and primary school age, according to Dr. Michel Pean, President of the Haitian Society for Support to the Blind. Only 1.7% of blind children attend school.

In 1996, an UNICEF programme estimated a prevalence of 9.7 ‰ of xerosis conjunctivae and of 2.5 ‰ of ulceration of the cornea. These figures are generally linked to a deficiency in vitamin A. The coverage of vitamin A throughout the country is about 60%, according to Catholic Relief Services (CRS).

Neonatal conjunctivitis is one of the major causes of blindness with a prevalence of 2.5%. "The most frustrating part is that it would only take one drop of argyrol, which doesn't cost much, to prevent the appearance of this disease, Dr Jean Hugues Henrys says, Director of the Ecumenical Mutual-Aid Service.

Vision problems, being ignored by both the public and private sectors, could constitute a major cause in staying behind at school, Dr. Michel Pean states. (⁹)

"The St-Vincent School has approximately 100 visually handicapped among its 250 disabled persons. The goal is to make them reach secondary school. For this, the principals and teachers of the schools which these children attend must be motivated to the cause, so that blind students can pursue their studies as normally as possible.

"These children have a slate and writing chalk which cost US$25.00, much less than the usual cost of a Braille machine of US$950.00. As for the books, these are transcribed into Braille. The St-Vincent school is about to purchase a scanner of US$ 5,000.00 which will allow a much quicker and more immediate transcription into Braille.

"Blindness has a cost. By the nature of his or her affection, a blind person requires a pretty continuous attention and therefore much more effort by those who are living with him or her." Reminding us of the fact that the blind are capable of integrating normally in the workforce, Dr. Pean suggests the public "to have a less blind look on the blind."

The ones cursed to hell: domestic and street children

There are actually around 10,000 street children. It is estimated that 14% of them is 5 years old or under. They are subject to stress, anxiety, malnutrition, typhoid, etc. Mrs. Maryse Flambert, the Minister of Social Affairs in January 2001, said that rallying points are being created where these children are helped to learn a job.

A child in domestic service (also called "restavèk" in Creole) is either a boy or a girl under12 years old, who, in exchange of a contribution to the household tasks of a family, receives shelter, protection, education, and care, according to the law in effect.(¹⁰)

Unfortunately, most children in domesticity hardly enjoy these conditions. Most of them are associated to people with salaries lower than Gdes 1,250.00 per month. Because of this fact and combined with the little consideration received, they are prone to many diseases such as: typhoid, gastro-enteritis, vitamin A deficiency, ARI and more and more sexually transmitted infections (STIs) including HIV/AIDS. (¹¹)

The parents have no money…

4% of the Haitian population monopolizes 66% of the resources. 70% of the population has only 20% of these resources and 10% does not have any resource. (¹²)

In the poor urban areas, called shantytowns, two-thirds of the population disposes over less than US$25.00 per month. In the rural areas, only one out of five households lives above the poverty line. (¹³)

Among 90,000 employees from both public and private sectors, 70% of those in private service earns less than 2,000.00 Gourdes monthly, and 70% in public service less than 2,800.00 Gourdes (data published by ECOSOF). The capacity of households to buy food continues to decrease further and further with the continuous increase of prices of basic goods as experienced during recent years.

These insufficient revenues confirm the results generated by various surveys which calculate the calorie deficit of the Haitian population at 35% (of the daily standard required of 2,200 calories) and the protein shortage at 20%.

Herslyne Michel, a household keeper who works in the residential area of Pacot (in Port-au-Prince) states that she was able to deliver her first baby in a hospital, but not the subsequent three, due to the increase in prices of basic goods. From 35.00 Gdes in 1985 when she had her first child, the price of a can of powder milk has risen to Gdes 75,00 nowadays; cow foot from 0.75 Gdes to Gdes 3.00; cow head from 5.00 Gdes to 15.00 Gdes; a measure of rice from Gdes 10.00 to Gdes 50.00; a bunch of plantain from Gdes 4.00 to Gdes 75.00 and even to Gdes 100.00; a cup of peas from Gdes 3.00 to Gdes 8.00.

Chart 1: Percentage of newborns whose mothers have benefited from prenatal care.

Education leaves much to be desired for…

In general, there is a significant relationship between a mother's level of education and the success of infant health programmes. In Haiti, this phenomenon is particularly striking. 95% of women with secondary school education against 53% of illiterate women seek medical assistance (See Chart 1). 43.6% of completely vaccinated children are born from mothers who have attended secondary school, against 21% born from illiterate mothers (See Chart 2). 3 out of 5 women who have been to secondary school against less than one third of illiterate mothers use re-hydration therapy to treat their children's diarrhea.

Chart 2: Proportion of completely vaccinated children between 12-23 months old.

What is the level of school attendance in Haiti? 63% of children from 6 to 12 years old go to school, well below the levels in Latin America, according to data published by the Ministry of National Education. Only 38 ‰ among the children who enter Kindergarten finish their secondary school.

Every year 12% fail to pass and 10 to 15% drop out of school. Just 3.5% of the teachers know how to teach the basic math programme of the fourth year.

… Mothers are stressed

"Continously and naturally stressed for economic reasons and the frequent abandonment by their husbands, Haitian women create mono-parental families and tend to pass on the violence of every-day life to their children, Dr. Bergren says, former Director of the Albert Schweitzer Hospital: "Kid, leave me alone, otherwise I'll make you pay for everything that makes my life difficult."

Impacts of urbanisation on children

The unplanned urbanisation in Haiti is 6.6%, a low percentage compared with urbanisation rates in other Latin American countries. But urban infrastructure is far from able to cater to this modest urbanisation: they are characterized by serious hygiene problems, poorly ventilated housing without running water or disposal systems for human excreta.

Port-au-Prince remains a small town and lacks the commodities that other urban agglomerations of its category possess.(¹⁴) The population of Port-au-Prince has gone from 507,000 in 1971 to 720,000 in 1982, and reached nearly 2 million in 1995. By now it is estimated that there are actually two-and-a-half million people in Port-au-Prince and its suburbs. (¹⁵)

Chart 3: Basic waste treatment - Percentage of population served (1980-1997). Update of the rate of coverage of needs in AEPA, 31 December 1997 (MSPP/DHP)

A good number of couples move around a lot. This great mobility favours occasional sexual relations, which increase the chances of exposure to sexually transmitted infections, including HIV/AIDS. The people involved do not know the health status of their casual partners, Dr. Eddy Genece acknowledges, Director of the "Foundation to Promote the Objective Zero-AIDS."

The rate of abandoning anti-tuberculosis treatment among children is greatly caused by this mobility of the population which is observed, Dr. Marie-Claude François thinks, Director of the Haitian Community Hospital at Frères, which cares for foster children of Plan Haiti.

Likewise, the failure of various preventive care campaigns for children is also attributed to the constant movement of the population, Dr. Dieudonne Jean-Baptiste says, former Director of Public Health in the Western Department.

A housing-unit in Port-au-Prince has an average of 6 people and often more. (¹⁶) In other cities, the situation is worse: 10.4 inhabitants per apartment in the city of Desdunes, 10 in Cap-Haitien, 6.85 in l'Estere, and 10.76 in the city of St-Marc. (¹⁷)

There is a clear link between the over-crowding of people in the same apartment and acute respiratory infections, one of the main causes of infant mortality, Dr. Françoise Ponticq of the Ecumenical Service for Mutual Support (SOE) says.

There are too many children for being taken care of properly

There is definitely a relationship between fertility, the number of children and the care provided to these children. "After the third child, the mothers stop going to a doctor," Dr. Regis says, paediatrician in Port-au-Prince. A seventh child has 5 times more chance to die than the fourth child, EMMUS III indicates.

EMMUS III finds that the fertility rate has hardly changed during the past 5 years, from 4. 8, to 4.7. This figure is very high in comparison with the average of Latin America, despite an improvement in the use of modern contraceptive methods. This went from 13 to 22% among the women living with a partner. Barely more than one woman out of 5 and one woman living in union out of 4 uses a modern contraceptive method. Although this number has doubled in urban areas, it has not changed at all in rural areas, where the population increases to an alarming speed.

A factor contributing to fertility, is the genesic gap, the period between two births. The preliminary report of EMMUS III shows that a child born four years after his brother or sister has twice less chance to die than children born at an interval of two or three years. Dr. Françoise Ponticq observed a 9-months genesic gap in a rural area.

It should be remembered that there is a clear relationship between premature pregnancy and neonatal mortality.

Early pregnancy also influences infant mortality and even infant-juvenile mortality, because a very young woman generally takes less care of her child. These facts are illustrated by the EMMUS III report, which states that a child has "one and half time more chances to die before the age of 5 when his/her mother is under 20 years old."

Government resources

Community health units (Unités communaitaires de Santé - UCS), established by the Ministry of Public Health and Population (MSPP), offer a minimal package of services under the aegis of general care of childhood diseases. It includes: vaccination, prevention, screening and treatment of neonatal pathologies, underweight at birth, urinary-genital infections, parasites, diarrhea, malnutrition and acute respiratory infections. At the maternal level are included the perinatal care, delivery assistance, post-natal care and family planning.

"The real contribution of UCS consist in networking the various health institutions or those with a health role in a specific geographic area. However, it is difficult to measure their real impact with regard to the improvement of health care. There are only two parts of the country where they operate satisfactorily, the Lower-Artibonite and Port-Salut," Dr. Emile Herald Charles explaines, Director General of MSPP.

On 25 July 2001, MSPP and WHO/PAHO organized a day of reflection on a new strategy of MSPP, entitled "Integrated Care for Childhood Diseases" (Prise en Charge Intégrée des Maladies de l'Enfance - PECIME). PECIME coordinates the provision of health care in integrated form.

"With regard to the objectives of this day, first of all it was to be aware of the impacts of the various programmes undertaken throughout the country. The main obstacle to the efforts of the Ministry lies in the scarcity of financial resources," Dr. Anne-Marie Desormeaux explaines, Director of the Department of Family Health at MSPP.

"We are going to stop living inside compartments. There is no longer ‘vaccination' on the one hand and ‘prevention' on the other, or care to be provided relating to ARI, etc. Both prevention and treatment should be carried out together," Dr. Charles says, who also explains that PECIME is the result of adapting a model created by PAHO/WHO.

"The reorganization of the services within health care institutions as well as the training of personnel will be the main practical implications of this new strategy," he concludes.

One percent of the GDP, or one tenth of the national budget, is allocated to public health. This means US$21.00 per inhabitant, a lower figure than the average of Sub-Saharan African countries (US$38.00), which have a GDP similar to Haiti. Haiti is far under the average for Latin America, which is US$202.00.

Eighty percent of MSPP's budget is allocated to salaries. MSPP is with its 18,100 employees the second largest employer in Haiti, after the Ministry of National Education. The country, which puts a lot of emphasis on primary care and health care for children, counts 1,848 doctors, 785 nurses and 1,844 assistant-nurses (records from 1998). With their low numbers, health agents in the field are faced with the absence of a structural training programme.

Among these 1,848 medical doctors, there are 550 general practitioners, 252 obstetricians and gynecologists and 211 paediatricians, which means one paediatrician for 160,000 children. More than 80% of the doctors, including the paediatricians, reside in Port-au-Prince.

The majority of Haitians need to walk for over an hour to reach the nearest medical centre, among those which are operational in this Caribbean Republic. "There is no medical centre available to pregnant women in the entire North-Western part of Haiti. This means for both obstetrical and neonatal emergencies a certain death sentence," Dr. Jean Hugues Henrys points out, Director of the Ecumenical Mutual Assistance Service.

The acquisition of basic materials is not the major problem of the Ministry of Health (as Japan actually provides oral re-hydration therapy, vaccines and a good quantity of essential drugs), but their delivery to the people who need them, according to Dr. Anne-Marie Desormeaux, Head of the Child and Nutrition Service at the Ministry of Public Health and Population.

Only 1/3 of the Haitian children is completely vaccinated, whereas a worthwhile coverage entails 80%, according to the figures of EMMUS II and EMMUS III. These surveys observe a progress from 30.2% to 33.5%. A national vaccination campaign was launched by MSPP on Sunday 7 January 2001.

"The population did not massively participate, in particular due to the insufficient number of health centres," Dr. Jacques Duc says, Chief of Service at the West health department.

A much more positive result obtained by MSPP is the promotion of breast feeding. Wherever exclusive maternal breast feeding has reached 50%, infant mortality has been reduced drastically, and hospitalization due to severe dehydration has spectacularly diminished or has even completely disappeared.(¹⁸)

This prevalence went from 0.6% to 49% after the launching, in August 1995, of the national campaign for promoting "exclusive breast feeding until the age of 6 months," EMMUS III observes. The paediatric service of HUEH strongly recommends the continuation of breast feeding during episodes of diarrhea.

It should be noted that, in case of acute respiratory infections, admissions to the hospital of children who have not received breast-feeding, are 17 times higher than those who are being breastfed. (¹⁸)

Table 3: Breast Feeding: Distribution (in %) of children from 0-23 months who are being breast fed or not, in association with complementary food, and percentage of those taking the bottle, in accordance with the number of months since the child's birth, EMMUS III, Haiti 2000.

External assistance

The cost of health care is very high in Haiti. In reality, the biggest share of health services depends on foreign assistance.

Although half of the primary care in the country depends on non-governmental organizations (NGOs), questions are being asked on the real effect of this form of international aid, which gradually could transform into a means of control. According to the Ministry of Planning, 29 NGOs currently work in the water provision and treatment sector and 27 NGOs in health.

Recently, these NGOs were severely criticized and the health commission of the Senate had an hearing about their activities.

"Projects which are ongoing or are to be implemented have allocated 70 million dollars to Cite Soleil, a shantytown which each day descends deeper into abject poverty," Dr. Ronald Villemay wrote in Le Nouvelliste of 23 November 2000.

The Haitian population has started to consider international assistance, in particular by NGOs, as an unfortunate but unavoidable evil, especially when one realizes that NGOs distribute 600,000 hot meals per day at a cost of US$52 million annually. This sum is mainly divided between USAID (18 million), Canada (15 million), the European Union (11 million), France (2 million) and Japan (2 million).

One of the most controversial aspects of this form of assistance concerns the three million dollars spent annually (based on information from MSPP) for Cuban medical assistance, initiated in 1998 by Fidel Castro and Rene Preval. This assistance does not focus on the primary health needs, but rather addresses the secondary and tertiary aspects, according to MSPP.

The presence of Cuban medical personnel has led to a doubling and even tripling of visits by the people to the health centres, as well as of the number of surgeries. Moreover, at present, several hundreds of Haitian students study medicine at the excellent medical school of Santiago de Cuba. However the Cuban press mentions numerous cases where Cuban doctors cannot really help the Haitian population, due to lack of materials and equipment. (¹⁹)

While by 2001 close to a thousand Cuban medical personnel are employed throughout Haiti, local practitioners from the countryside migrate massively to the capital. (¹⁹) In the long run, this risks to make the rural population dependent on foreign assistance.

Some examples that work

One of the most encouraging examples in the Haitian health sector is provided by the Committee of the Charity Hospital in Pignon. Following an agreement signed twelve years ago in 1989 with MSPP, this hospital has recorded infant-juvenile and infant mortality rates which are lower than the average of Latin America: 17 ‰ and 10 ‰ respectively. (²⁰)

"Discipline, presence in the field, and integration of the people at all levels of decision-making are the keys to our success," Dr. Guy Theodore says, founder of the hospital and a native of this town.

In Pignon, there are 155 assembly centres and 554 health agents. Traditional healers are also integrated in health care. 500 children benefit from scholarships among which scholarships for university studies both nationally and in foreign countries.

"All the scholarship recipients come back to us, to put their knowledge into the service of the population of this region," Dr. Theodore informs.

Another example of success is provided by the Albert Schweitzer Hospital, located in Deschapelles. Founded by the Mellon couple in 1956, this hospital has drastically transformed the status of health of the inhabitants of the Lower-Artibonite, and even nationwide.

Per year, 114,000 women in childbearing age are inoculated against neonatal tetanus. The prevalence rate has become nil after a eradication campaign was carried out in 23 villages. (²¹)

In the region served by the Albert Schweitzer Hospital, the rates for infant and juvenile mortality are respectively half and one-third of those in the rest of the country. A set of techniques, being offered to mothers, was established by Dr. Lucien Rousseau. Through the World Health Organization, these techniques have been exported all over the world.

In the South-East Department, Plan Haiti financially assists the extension of preventive health care, as provided by a group of NGOs in collaboration with the Health Directorate of the South-East. Plan Haiti is an organization that at the national level supports 48,000 children directly (this is 2% of the population under 15 years old) and 250,000 persons indirectly. With limited means (such as some affordable drugs and the use of a referring system already in place), Plan Haiti and its partners realize a programme aimed at education and prevention. This programme promotes exclusive breast feeding, family planning, vaccination, the distribution of vitamin A, the prevention of neonatal tetanus, etc. In addition, Plan Haiti supports, in a more restricted way, the treatment of the most common childhood diseases.

"What Plan cannot afford financially, is compensated by the participation of the population," Bruno Oudmayer, Director of Plan Haiti, points out.

"The work of facilitators, volunteers, organizers and the general public can absolutely not be divorced from our achievements. For example, there are the organizers who enable the distribution of the condom "Kapot Pantè" and the contraceptive pill "Confiance."

"The educational messages are not only well known by the population thanks to the time devoted by volunteers to education and to dialogue, but we also receive feed-back and are made aware of the real needs of the people. In this way, we can keep modifying our strategy accordingly," Bruno Oudmayer adds.

Plan Haiti had also begun to foster AIDS orphans through a programme carried out in collaboration with "Maison Arc-en-Ciel" (the Rainbow House).

What are the perspectives for the health of Haiti's children ?

The health programme of "Fanmi Lavalas" (Lavalas Family), the political party currently leading the executive and legislative powers in Haiti, plans to reduce the infant mortality from 80 ‰ to 40‰ between 2001 and 2006, to work with the traditional healers and to integrate the private sector in health care. (²²) The former Minister of Health, Amedee Gedeon,(²³) showed a sample of the 150 first aid kits that she plans to send to the new medical centres, because "the minimum would be that each rural section has its own health centre."

A new medical centre will soon be added to the GHESKIO Centres (Haitian Group for the Study of the Karposi Syndrome and Opportunistic Infections) and to the hospital of Dr. Paul Farmer in Cange (Peligre, Central Plateau) to control the transmission of HIV to newborns, Dr. Michaelle Amedee Gedeon says.

Thanks to the drug AZT, the transmission rate from mother to child has gone down from 30% to figures close to 10%, according to Dr. Gedeon. The decision to enhance the autonomy of the departmental directorates will allow to reduce the administrative costs within the budget.

Ninety-three percent of Haitians think that the government will not be able to achieve its objectives without international assistance – which is conditioned to the solution of the political crisis - according to a survey conducted by HAITISCOPIE in February 2001 and published by the daily newspaper "Le Nouvelliste" on 22 March 2001. Only 5% thinks that the country can do without this aid.

In the short term, the political issue is the most formidable threat. Due to the non-ratification of the new Prime Minister by the 46th legislature (1997-1998), 50 millions US dollars allocated to MSPP could not be released, according to Dr. Gedeon, who talks about the blockage of direct bilateral assistance to Haiti in the area of health since several years.

"With this sum, we could have saved many children. If for one reason or another, the national and international political communities take the Haitian people hostage, the consequences will be not only an increase of poverty, but an increased number of children's deaths and a physical and intellectual handicap which is difficult to overcome for those who survive," Dr. Gedeon exclaims.

The health situation during the embargo, imposed on Haiti between 1991 and 1994, brings a lugubrious confirmation to the words of the former Health Minister. During this period, the infant mortality increased to 16% in the area of Maissade, according to the Harvard School of Health. Moreover, serious malnutrition in many parts of the country progressed from 6 to 32%, according to a study conducted by the Nutrition Center.

In the end, the most brilliant health strategies always encounter two unavoidable factors: economic and political. The future will depend on the true priorities of Haiti's principle actors on the political scene (government, political parties, private sector, international community), as well as the real opportunities for the Haitian people to express their true hopes.

Gwen Mellon, who together with her husband created the Albert Schweitzer Hospital at Deschapelles, said one day: "I never lost faith in Haiti."

Some references:

Association Médicale Haïtienne (AMH)
33, 1ère Avenue du Travail
Port-au-Prince, Haïti
Email: amh@haitiworld.com

Catholic Relief Services (CRS)
1, Delmas 81
B.P. 1118
Port-au-Prince, Haïti
Tel: (509) 249-1992/ 510-4586

Centre de l'Éducation spéciale (CES)
Rue de l'enterrement # 73
Port-au-Prince, Haïti
Tel: (509) 223-6167/222-2154/5547

Hôpital Albert Schweitzer
(Deschapelles, Artibonite, Haïti)
1410 Magellan Drive, Suite 101
Sarasota, FL 34243, U.S.A.
Email: hopitalas@aol.com

Hôpital de Bienfaisance
(Pignon, Plateau Central, Haïti)
CMC, c/o MF Box 15665
West Palm Beach, FL 33416, U.S.A.
Fax: (509) 257-3001
Email: WCRF2001@aol.com

Institut de Bien-être social et de recherche (IBESR)
Ave. des Marguerites No. 14, Bois Verna
Port-au-Prince, Haiti
Tel: (509) 245-2602 / 2601 / 6485 / 2633

Institut Haïtien de l'Enfance (IHE)
41, Rue Borno
B.P. 15606
Pétion-ville, Haïti
Tel: (509) 257-3101/ 1508/ 510-8438

Maison Arc-en-Ciel
Rue Beaulieu, Boutilliers
Pétion-ville, Haïti
Tel: (509) 246-5596 / 557-2948
E-mail: arcenciel@acn2.net

Ministère de la Santé Publique et de la Population (MSPP)
Palais des Ministères
Champ de Mars
Port-au-Prince, Haïti

Organisation des Nations Unies pour l'Enfance (UNICEF)
17 rue Armand Holly, Debussy
B.P. 1363
Port-au-Prince, Haiti
Tel: (509) 245-1404/1424
Fax: (509) 245-1877

Organisation Pan-américaine de la Santé / Organisation Mondiale de la Santé (OPS/OMS)
295 Ave John Brown/Lalue
B.P. 1330
Port-au-Prince, Haïti
Tel: (509) 245-0764 /8666/ 8695
Fax: (509) 245-1732

Plan Haiti
Impasse Lily No. 3, Rue Stephen
Delmas 60
Port-au-Prince, Haiti
Tel/Fax: (509) 256-1438 / 4229
Email: comhti@planinternational-ht.org

Endnotes

1. Desinor O.I., Adrien J.C., Jean Baptiste J., Larco P., Magloire R., Desormeaux A.M., Desormeaux J., Aris Guieta C., Haitian Society of Paediatrics (SHP)/Ministry of Public Health and Population (MSPP)/World Health Organisation (OPS/OMS) : Survey on the mortality and morbidity of children 0-5 years of age living near the Haitian/Dominican region border. Port-au-Prince, March 1998. Published in the Bulletin of the Haitian Medical Association, January-March 2000.
2. Cayemittes M., Rival A., Barriere B., Lerebours G., Amedee Gedeon M. : Survey, Mortality, Morbidity and Use of Services (EMMUS II), Haiti 1994/5. Calverton Maryland, Haitian Institute for Childhood and Macro International Inc., 364p.
3. Survey, Mortality, Morbidity and Use of Services (EMMUS III), Haiti 2000. Preliminary Report. Haitian Institute of Childhood (IHE) Demographic and Health Survey, ORC Marco International Inc.
4. Analysis of the sanitary situation in Haiti 1998. MSPP, WHO/PAHO.
5. Les facteurs de risque de la mortalité infantile dans la population rurale de 6 communautés haïtiennes (Infant mortality risk factors among the population of six haitian rural communities). Dr. Françoise Ponticq, September 1997, Mémoire en vue de l'obtention du diplôme d'Université en Santé Publique et Communautaire/ Université de Nancy, France.
6. Report on World Development 1998/1999, World Bank
7. IHE/Gheskio Centres/PAHO/WHO: Results of the surveillance study on the prevalence of HIV, Hepatitis B and Syphilis among pregnant women in Haiti.
8. HIV/AIDS and street children in Haiti, by Martine Bernier and Paul Ascencio, August 1992, Dept. of Social and Preventive Medecine, University of Montreal.
   Planning of interventions using the methods of social and economic organization of children and youth living and working in the streets of Haiti, among which those who live of prostitution. Martine Bernier, M,Sc., Francoise Ponticq, November 1999.
9. Magazine of the Haitian Medical Association, January-April 1999.
10. Haitian Civil Code and Law of 12 December 1960. See also Labour Code François Duvalier.
11. ISOFA/UNICEF : Juvenile domesticity in Haiti, 1998.
12. Bulletin published in 1995 by the State Secretary for population.
13. Survey done over 4,026 household in Cite Soleil from 1994 to 1996, financed by USAID.
14. Georges Corvington. Port-au-Prince over the years. The Haitian Capital in Twentieth Century
15. Haitian Institute of Statistics
16. Haitian Institute of Statistics
17. Evaluation of a sanitary survey on the distribution of drinkable water, status of water treatment and garbage management, February 1990.
18. British Journal of Medecine, December 1999
19. Report of the Consultative Committee on the Cuban Health Assistance, Haitian Medical Association, 11 October 1999.
20. Charity Committee of Pignon (CBP). Statistics of CBP, January-December 1999. Prepared by the staff responsible for the Statistics Section.
21. Albert Schweitzer Hospital – Deschapelles, Haiti. Press Release, September 2000.
22. Fanmi Lavalas Organization – Economic and Social Programme 2001 - 2006.
23. Interview was done in February 2001.

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