When the first case was confirmed on March 19, Haitians were already experiencing an upsurge in gang-associated activities, a spate of kidnappings, a falling currency, weeks of school closures, and a population deeply dissatisfied with the political leadership. In the context of these chronic ills, the rapidly escalating COVID-19 in Haiti represents an existential threat to the socio-economic life of the country.
From its birth via revolution of an enslaved people, and throughout its 206 years of age, Haiti has known a tumultuous national life, external interference in its internal affairs, and socio-political traumas that paralyze its development and have historically contributed to the unnatural impact of disasters. 10 years ago, an earthquake killed more than 250,000 people, displaced 1.3 million, and Vibrio cholerae was introduced, causing a massive epidemic of cholera with more than 800,000 cases, and 10,000 deaths. In 2016, Hurricane Matthew killed more than 500, and devastated the livelihoods of nearly 2 million people in southern Haiti. These events contribute to the fact that more than 6 million of Haiti’s 11 million people live on less than US$2.41 per day.
For the past three years, Haiti has continued to experience a succession of events that rekindled old wounds. In 2018, repeated gas shortages throttled the country and an anti-corruption movement “kot kòb Petrokaribe?” (Where is the Petrocaribe money?) involved massive demonstrations. For days in July 2019, and then repeated for weeks in October and November of 2019, a protest strategy named ‘‘peyi lòk’’ (locked lountry) forced people in the cities to be confined to their homes, and roadblocks throughout the country. In 2019, food insecurity reached record highs with 49.3% of the population undernourished, placing the country in the worst position in the Americas. This was accompanied by renewed and accelerated gang activity in different corners of the country.
Despite evidence from other countries, including neighboring Dominican Republic, warnings of a leading Haitian scientist, and the inadequacy of the health system to meet any substantial increase in patients, the Haitian state has been slow to respond effectively to the prospect of an imminent catastrophe. There have been efforts, but these have lacked a cohesive message, focused on showing ability to care for just the first few patients, and lack of investment in the standard public health approach to outbreak containment – testing, tracing and isolating. This is ironic considering that lessons from contact tracing in Haiti in part inspired the Governor of Massachusetts, USA to invest in the approach. While promoting physical distancing in principle, the Haitian government allowed re-opening of low wage factories.
At the time of writing, 533 cases of Covid-19 have been confirmed, with 21 reported deaths. News reports suggest a higher death toll. We saw a similar challenge in the early stages of cholera, with many community deaths never being reported. Ministry of Health statistics also suggest some bias in sampling – amongst reported deaths, one third are in young people under 45 years.
Having worked as doctors in public health in Haiti for almost two decades, we have been frequently faced with skepticism of those at home and abroad who think that it’s not worth being ambitious in Haiti. There are indeed substantial challenges: how to support self-quarantine and isolation in the most densely populated country in the region; what provisions for the food insecure, the many homeless in the capital and marginally housed nationwide? How to manage the material impossibility of social distancing when livelihoods depend on the informal commercial sector? Importing personal protective equipment (PPE) and testing supplies is also a major challenge for poor countries, worsened by USAID refusal to allow purchase of PPE with its funds. Decades of foreign investment in Haiti via international non-profits, has left Haitian public institutions standing largely alone now, with talented implementers, but without the capacities they might have had – a handful of functional intensive care unit beds, for example, or access to safe water not much better off than it was a decade ago.
Yet we have seen Haitian ingenuity and science in action, and we know that transformative health programs are possible in Haiti – we have played a role in some of them. Our Haitian colleagues are building facilities, caring for patients, establishing testing for Covid-19, and support has been pledged from private sector, bilateral and multilateral donors. But it’s not enough. Testing must be massively scaled up, workers need protection with effective PPE, and radical social support will be necessary. USAID must support the procurement of critical Covid-19 supplies, and the US must cease deportations, which risk worsening the Haitian epidemic. The Haitian people need support from their regional neighbours and transformative leaders at home – to unite the country and make smart decisions in the face of what may be the worst disaster the country has ever faced.
About the authors
Louise Ivers is a practising infectious diseases physician, executive director of the Massachusetts General Hospital Center for Global Health. Loiuse is an associate professor of Global Health and Social Medicine at Harvard Medical School and has worked in Haiti for 17 years with Haitian and international non-profits, as well as in collaboration with the Haitian public health sector.
Jean-Gregory Jerome is a Haitian physician and global public health specialist who has worked for almost two decades in the Haitian health system including in public sector and non-profit sector.
Conflicts of Interest
The authors do not declare any conflict of interest.