Haiti's health beyond the quake
The biggest barriers for Haiti's health in the future remain much the same as they were before last year's quake.
Despite the more than 171,000 cases of cholera and other common infections from malaria and typhoid, the most frequent causes of death in the country have nothing to do with infectious diseases. "The number-one cause of death in Haiti is cardiovascular disease," Garfield says. But distributing blood pressure medication and promoting healthful lifestyles might not easily get top billing in a country whose presidential palace remains in ruins.
On the other hand, a brick-and-mortar solution could help bring down the second-most common killer in Haiti: injuries, which Garfield describes as "the single greatest opportunity for simple or easy prevention of death." Motor vehicle injuries and deaths—especially those involving pedestrians—are common, and many could be avoided simply by installing curbs to help separate cars from people, he explains. Improved driver education and traffic control would also go a long way in boosting basic public health and safety, but, he says, "there really has been no attention to that."
In the long run a key to a healthier Haiti will be slowing population growth, says Garfield, who first visited Haiti in 1968, and notes that overpopulation has been an issue for at least the past 25 years—stretching limited government resources thin. "Fertility has declined a lot," he says, "but not nearly as much as it needs to."
The bottom line is that public health in Haiti is "not much different than a year ago" before the earthquake, Garfield says. He acknowledges that training and surveillance have begun to improve. But, he and other public health experts contend, substantial resources need to be invested in boosting the skills of local workers—especially in the health and medical fields. Aside from creating jobs, better-trained doctors, epidemiologists, nurses and researchers will help allow international agencies to start pulling out.
Some advocates have argued that the influx of volunteer health workers and free services actually depressed the job demand for locals. Garfield does not deny that the market has likely been undermined, but, he says, "It's really crocodile tears if you want to imagine that as the golden days." As part of the transition to locally based care, he notes, many NGOs are now starting to train and hire Haitian health care workers.
"I do think it's possible" to build a healthier Haiti than existed before the quake, Galea says. "I don't know that it's likely," he adds. "I think it will require both financial investment and political capital."
If all goes well in Haiti, politically and economically, Garfield estimates it might still take five to 10 years to see solid strides in public health progress. "These things are not going to change overnight anywhere," he says. But he does not chalk up Haiti as a hopeless case. He sees potential for peaceful change of political power and for the country to boost profits in local industries, including agriculture, garment-making and tourism.
The great challenges to rebuild Haiti's health and public infrastructure might be seem like steep uphill battles but, as most experts point out, the main drivers for recovery must be more top-down. "In the end, the ultimate responsibility lies with the government," not the commission or international agencies, Karunakara said. "It has to be the government in coordination with the people."