Much of Haiti's population of 10 million already lacked reliable access to ambulance services, clean water and good sanitation before a magnitude 7 earthquake struck there in January 2010. Now, after receiving billions of dollars in aid and a small army of volunteer health workers, has the country climbed onto more stable ground for health?
The short answer is, no. But the significant challenges facing Haiti in ensuring the health of its citizens involve factors more complex than temporary housing camps or damaged hospitals, public health experts say.
"The central public health concerns are in many ways the central reconstruction concerns," says Sandro Galea, chair of the epidemiology department at Columbia University's Mailman School of Public Health.
Without foundational social, political and economic infrastructure, such as plentiful jobs and rebuilt neighborhoods, he notes, "you end up being exposed to many more risks to your health," such as violence, depression and poor diet.
But building new sewers and reforming government agencies are hardly the issues that play easily on international sentiment. In the immediate wake of the quake aid and volunteer offerings poured into the country, much of it targeted to addressing very immediate—and very real—needs, such as providing first aid, food and water. "There has been a massive influx of international volunteers and organizations," says Richard Garfield, a professor of clinical international nursing at Columbia University's School of Public Health. "But those actions are largely short-term, and what will make a real difference is jobs and governance." Transitioning international goodwill to long-term improvement looks itself like many roads in Haiti: rough and unclear.
A "republic of NGOs"
Just as the earthquake was little surprise to some seismologists, Haiti's intense vulnerability was familiar to the international aid community. "There was a big problem in quality of care, particularly in health services that poor people had access to," Galea says. "I think the earthquake has exacerbated this, and it will be slow rebuilding.
In large part because of its persistent poverty Haiti had long been host to a cadre of nongovernmental organizations (NGOs) that provided health and other services that the government was unable to supply. Infrastructure in place for international government and NGO programs such as the U.S. President's Emergency Plan for AIDS Relief and Partners In Health, respectively, were transitioned to help with response needs after the earthquake.
"Haiti was and remains the republic of NGOs," Garfield says. He acknowledges that "the large influx of international voluntary health workers was remarkably successful in providing primary care." Because access to fundamental services had been relatively spotty before, many Haitians received basic health services after the earthquake that they had not had access to before the disaster.
Some specialized services, however, proved to be mixed blessings. With so many surgeons entering the country, Garfield says, after the earthquake the country had "a rate of amputations that is about double of what it should have been"—in part because "cutting is what they do."
After the initial rush of action following a major disaster or conflict, there is what Galea refers to as the "then what?" period. "Relief agencies can be quite good at providing for [infectious] diseases in the short term, but the challenge is transferring from these relief agencies to a more permanent infrastructure," he says.
And for organizations that have been meeting in-demand needs, dialing back their work can be tricky. "It's not always clear when humanitarians should exit," Doctors Without Borders (Médecins Sans Frontières, MSF) president Unni Karunakara said in a briefing on Monday. He pointed out that as a medical agency, the needs they serve never really go away. But before the NGO begins to pull out of Haiti (which, he noted could be two to five years away), "we want to see that a certain level of services are being provided by other actors," such as Haiti's Ministry of Health or even other agencies, he said.
This hurdle is not unique to Haiti, Galea notes. In many countries when a humanitarian crisis hits—whether it is from a natural disaster, political unrest or another cause—NGOs and other agencies "parachute in" and create excellent services. But many groups end up having to leave eventually, and if the services are not integrated with local systems, they can leave large coverage gaps.
"I think there has been progress made [in determining] what needs to occur to get Haiti to a healthier place," says Daphne Moffett, deputy director for the Health Systems Reconstruction Office at the U.S. Centers for Disease Control and Prevention's Center for Global Health. "The idea is to work with the Ministry of Health, so that they are able to define what it is they need."
Many independent organizations have been hesitant to get involved too deeply with the nation's Ministry of Health. "Almost nobody has provided personnel to work along with the very small and very poorly trained staff" at the health ministry, Garfield notes. "And nobody wants to get involved because it's dirty and messy."