Haiti: Unjust Aid Embargo
During Health Emergency
I write to report on conditions in Haiti's
central plateau, where we have for the past 18 years delivered
health services to the region's poor. The current climate
is one of continued deterioration of social conditions, due
in large part to lack of resources, medical personnel, and
a growing burden of disease. The causes of worsening conditions
are many, but it is possible indeed, imperative
to underline the direct connection between unnecessary suffering
and death and an aid embargo, which has dramatically diminished
the ability of the public-health system to respond to the
needs of the Haitian people.
The Duvalier regime was aptly termed a "kleptocracy,"
in large part because of its mismanagement of foreign aid,
much of it from the United States. Since the fall of the
Duvalier dictatorship in 1986, there have been only brief
periods in which public-health officials, in concert with
a broad range of partners, have been permitted to implement
a series of projects designed to improve health conditions
in Haiti. The 29-year long regime was followed by military
rule and, within years, by a military dictatorship. Generous
aid continued to flow during much of this time, but very little
of it seemed to reach its intended beneficiaries.
In 1990, democratic elections brought new hope to those working
to improve health conditions in Haiti. A military coup in
1991 brought an abrupt end to that hope. In central Haiti,
we documented both worsening social and economic conditions
and a paradoxical decline in the number of patients seen:
our clinic was targeted by the military for repression and
threats, events we have described elsewhere. The impact
of the military coup on Haiti was severe in the short-term,
with thousands killed outright and hundreds of thousands displaced.
The decline in health status during the following three years
was catastrophic: epidemics of measles and other vaccine-preventable
diseases were reported, as were outbreaks of dengue fever.,
,  Infant and juvenile mortality, and also maternal
mortality, are the highest in the hemisphere. HIV and tuberculosis
became the leading infectious causes of young adult death.
Most of these diseases were tightly tied to increasingly prevalent
malnutrition. The nationwide network of public clinics and
hospitals was left to fend for itself, and many health professionals
left Haiti as this network foundered.
All this was to change with the restoration
of democratic rule in 1994. At this time, a broad coalition
of international donors announced a plan to commit some $500
million of aid to Haiti. Without an infusion of capital, it
was agreed, it would be impossible to rebuild Haiti's battered
health and social-services infrastructure. A number of projects
designed to revive public health and education, as well as
its transport systems (most roads had been destroyed), were
developed and approved by the Inter-American Development Bank
(IADB) and other funding agencies. For a variety of reasons
none of them related to the most pressing need in the Western
hemisphere this aid has never been made available.
The intervening years have seen a resurgence of infectious
diseases, a decline in life expectancy (the only such decline
documented in the hemisphere), and enormous demoralization
among medical personnel.
These strictures became even more pronounced
over the past year, during which a formal aid embargo has
been declared by the United States. This embargo has blocked
the IADB-funded projects already approved by both the Bank
and by the Haitian parliament. The commission fees for the
loans are accruing even though no monies have been disbursed.
In fact, in spite of dramatically increased parliamentary
capacity to pass legislation to promote public health, the
government has been prevented from implementing projects supported
broadly by the Haitian people. The aid embargo has in effect
rendered the Ministry of Health incapable of reviving the
national network of clinics and hospitals; even vaccination
programs have faltered. Again paradoxically, a number of clinics
and hospitals have been abandoned by both patients, who cannot
pay for medications, and by medical personnel. Cuban medical
aid, though admirable, has been restricted largely to medical
personnel. Without money and medications, the impact of such
aid is sharply limited.
Allow me to sketch the impact of these processes on the 80-bed
hospital of which I am the medical director. With a staff
of 8 Haitian physicians and a large corps of community health
workers, Zanmi Lasante is one of the largest charity hospitals
in Haiti. We have never received significant government assistance
or funding from the IADB or USAID; thus we are in a sense
neutral observers of the events described above.
In another sense, however, we are victims of the collapse
of the public-health system. As clinics and hospitals in the
region close or turn away patients due to their inability
to pay, the patients have come to our facility. In the Departement
du Centre, where our facility is based, the commune of Thomonde,
with 40,000 inhabitants, was without a single doctor or nurse
during the past year. As a result of faltering or poor services
elsewhere in the region, we routinely receive 300 patients
per day, which has overwhelmed both our staff and our resources.
The Haitian Ministry of Health, the only institution with
a mandate to serve the entire population, has been a willing
partner but has been strapped by such financial constraints
that its assistance has been limited to training.
To attempt to sketch the impact of the aid embargo on social
conditions and our capacity to respond to grave health problems,
allow me to cite certain examples:
Over the past year, our general ambulatory clinic has seen
an enormous increase in demand. We are staffed to receive
no more than 25,000 visits per year, but will this year see
an estimated 60,000 patients. Meanwhile, visitors to neighboring
facilities have found them to have very few patients. While
several neighboring facilities remain open, they sell or prescribe
medications at prices that are beyond the reach of the population,
over 80% of which lives in poverty.
HIV continues to spread within Haiti. Although the Haitian
epidemic has been contained more effectively than in many
African countries, it is the gravest in the hemisphere.
A national AIDS plan was advanced at last year's United Nations
Special Session, with First Lady Mildred Aristide leading
the delegation, but this plan widely regarded as sound
by experts remains unfunded. Meanwhile, U.S. and
World Bank assistance for HIV prevention has continued to
flow to other less gravely affected countries in the region
(at one point, a "Caribbean-wide" AIDS initiative
with a proposed budget of over $100 million had not a penny
allocated to the country with an estimated 65-70% of all the
Tuberculosis remains a major cause of adult mortality. Again,
the prevalence of TB is thought to be the highest in the hemisphere,
with active case finding suggesting prevalence more than ten
times as high as other Latin American countries.,
At the same time, it is of note that the Haitian National
TB Program has continued to receive international donor support
and has thus managed to continue to procure and distribute
medications. We have not experienced drug stockouts, even
though we receive all first-line drugs from the Ministry,
and thus although our case rates are rising, mortality remains
low within our catchment area and others working in concert
with the National TB Program.
We have registered a rise in trauma cases due in large part
to road accidents. The sequelae of accidents are more serious,
since patients are required to travel farther to receive care
and many require, and do not receive, the care of orthopedic
and trauma surgeons.
Malaria remains a major contributor to anemia and death. In
our facility, malaria is the leading single diagnosis during
the rainy season. Deaths continue to occur, even though Haiti
has not yet registered chloroquine-resistant cases. Lack of
access to care remains the primary problem.
Polio, previously believed eradicated from the Western hemisphere,
has again resurfaced on the island. Whether wild type or vaccine-related
strain, polio virus will continue to spread if national vaccination
efforts are not supported through Ministry programs, since
national coverage is imperative.
We have documented outbreaks of anthrax, meningococcus, and
drug-resistant tuberculosis. The degree to which these pathogens
spread will be determined largely by the capacity of the public
health system to respond.
Of course claims of causality are always difficult to prove,
but whether these conditions are caused or not by international
policies, it is clear that aggressive humanitarian aid could
have an immediate and salutary impact if it can be channeled
through institutions with national reach. Increasingly, however,
aid has been decreased or funneled to non-government organizations
that make largely local contributions.
I have worked for almost 20 years in Haiti and have seen U.S.
aid flow smoothly and generously during the years of Duvalier
dictatorship and the military juntas that followed. As a U.S.
physician, I believe it shameful that the current embargo
has been enforced during the tenure of a democratically elected
government. Such policies are both unjust and a cause of great
harm to the Haitian population, particularly to those living
Paul Farmer, M.D., Ph.D.
Harvard Medical School