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.[1] 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.[2]

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.[3] 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.[4], [5], [6] 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.[7] The intervening years have seen a resurgence of infectious diseases, a decline in life expectancy (the only such decline documented in the hemisphere)[8], 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.[9]

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.[10] 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.[11] 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 region's cases).

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.[12],[13] 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.[14]
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 in poverty.

Paul Farmer, M.D., Ph.D.
Medical Director
Zanmi Lasante
and
Professor
Harvard Medical School