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."

The Interim Haiti Recovery Commission, led by current Haiti Prime Minister Jean-Max Bellerive and President Bill Clinton, has promised to help coordinate incoming aid and in-country reconstruction efforts. But many observers point out that the commissioners have met infrequently, been slow to hand out aid money, and produced few tangible results. Stefano Zannini, MSF's head of mission in Haiti, noted in the Monday briefing that although coordination of so many agencies is a massive task, "you have a lot of people sitting around the table talking about what they would like to do, what they could do." But to get the country and its people back in the pink, he said, "there has to be coordination of action, rather than coordination of intention."

Camp life
Despite all of the assistance health workers have brought to Haitians in need, visiting physicians are not engineers. "The cholera epidemic shows us a whole other aspect of health," Garfield says. "No matter how many nurses and doctors are there as volunteers, it is not going to affect sanitation." And these basics, such as clean water and sanitation, Moffett says, are what it's going to take to give public health necessary footing in Haiti.

MSF, for example, has depended on other agencies and the government to clear waste and provide water in order to be able to proceed with care for locals. With political unrest that occurred after preliminary election results were announced in December, "there were disturbances that meant, for example, that water trucks could not get through," Zannini said. Echoing Zannini's sentiments, Karunakara said, "I would like the national authorities to assume more of their responsibilities."

One of the ways the reconstruction commission or government could be doing more, Zannini said, was to hasten reconstruction of residential areas so that displaced people could move out of the temporary encampments in which they have been living.

Soon after the earthquake many public health experts worried that close quarters in the displaced-persons camps would lead to outbreaks of infectious diseases. Some are pointing to this fall's cholera outbreak as evidence of this inevitability. But as Garfield points out, "the epidemic got going in the Artibonite Valley, where there are hardly any displaced people."

The camps, in many instances, are offering people better access to clean water, sanitation and health services than they had before the earthquake. "One reason you can't get people out of the camps: because things are better there than they were" before the quake, Garfield notes.

After having lived in the camps for close to a year, many people have adopted them as their new homes and neighborhoods. "They've become sort of settled into these camps—they have neighbors and clinics and know where to go for help," Moffett says of the displaced Haitians.

A lack of jobs has also deterred many from being able to move back out into the broader community. Moffett contends that compared with when she first landed on the ground in Haiti a week after the earthquake, "the economy, since January, has come back online."

But without access to independence—financial and otherwise—many people continue to feel the mental strain of the disaster. Galea and his team have been tracking mental health issues following the temblor. Their data are currently under review for publication, but, he says, "we have evidence for pretty substantial mental illness as a result of the earthquake."

Most mental health issues usually appear soon after a major event and are likely to resolve themselves within six months or so, Galea says. But with so many people still lacking jobs and resources to get on with their daily lives, any additional hardships can lead to increased psychological stress.

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."