Health Threats to the Children of Haiti: Cholera, Malnutrition, And Violence

Introduction

The purpose of this commentary is to discuss the declining health situation of Haiti’s children as that society attempts to cope with the issues and events associated with its status as the poorest country in Latin America and the Caribbean. As Haiti’s children grow and develop, they must face an environment regularly marked by: hurricanes, floods and earthquakes, political instability, economic decline, institutional and organizational failures, limited health care opportunities, cholera and other diseases, poverty, food insufficiency and malnutrition, social disorder, and terrorism and violence by spreading violent gangs.

In the following I discuss facts about health in Haiti, the concept of cumulative chronic stress in Haitian children and their prospects of health for the future. Upon completion of a four-day visit to Haiti Manuel Fontaine of UNICEF observed, “In Haiti right now, there is a triple threat to children’s livesmalnutrition, cholera, and armed violence. And sometimes all three together “[1]. The physical and social ecology of Haiti is very difficult for adults to adapt to and thrive in and it is even more so for children [2]. Haitians even at their very best have had a hard time making the political, social, and environmental systems work. With health care and administrations interventions by well-meaning national partners including the UN, USAID, PAHO, the World Bank and numerous NGOs, things still remain very difficult in Haiti. While our primary focus in this discussion is on children, we begin our observations with the broader context of overall health care facts in Haiti [3].

First, there is a lack of first-rate medical treatment facilities because of the frequent near devastating pounding the island receives from hurricanes, earthquakes, floods, and landslides. Haiti is in the fundamental path of serious storms. In recent hurricanes, 50 health centres affiliated with Haiti’s main teaching hospital were destroyed.

Second is the continuing effects and health care strains of Haiti’s battle with cholera. The disease came first came to the island to in 2010. At that time the UN had a number of foreign troops in occupation to help Haiti cope with the devastating earthquake of that year. They brought cholera with them, and the infection spread widely. Eventually, public heath people got cholera under control, unfortunately, it broke out again in 2023.

Third is pervasive child malnutrition, which contributes to childhood mortality. Approximant 20 percent of Haitian children suffer from severe malnutrition and about 7 percent of Haitian children die before their fifth birthday. Children surviving the onslaught due to malnutrition due to their limited nutrient intake as they grow are likely to experience physical and mental limitations as adults [4].

Fourth, a widespread lack of preventive health care characterizes the population in general. Curative medicine is more often sought by both the population and provided by health care agents. Several factors contribute to reliance on curative rather than preventive measures:
1. the high frequency of serious periodic environmental disruptions which simply demand immediate attention.
2. the low number of professional health care providers in the country; and d
3. patterns of health care funding that adhere to curative health care rather than to preventive medical practice.

Fifth, is the low public expenditure on health care. The national budget for health care has been low and continues to get lower. The national budget for health care has decreased from 16.6 percent for health care to 4.4 percent. In addition to these overall five health characteristics, there are additional facts of life in Haiti that provide the backdrop for children’s health and life [5]. The first is the contrast between urban/rural conditions. In the capital of Port-au- Prince, living conditions have been improving since the last round of hurricanes and earthquakes. However, it is a different story in the rural areas [6]. Poverty rates have remained high. The rural areas have received less help in rebuilding since the last round of disasters. Second, access to safe drinking water is a major problem in both urban and rural areas. Contaminated water makes cholera and water borne illnesses more likely. Haiti has the lowest access to clean water and sanitation infrastructure in the Americas. However, the Centres for Disease Control and Prevention (CDC) and partners are working hard to improve the safe quality of water, sanitation, and hygiene [7].

Third, housing quantity and quality have presented major problems for many years. Recent major storms have made it worse. Consequently, many people and families have found accommodation in already over-crowded residential spaces. Others live in tents or other makeshift dwellings. The need for housing is acute for children, as UNICEF has observed after the last major earthquake, “The children of Haiti face a challenging situation after the earthquake that hit the country, destroying houses, schools and hospitals— killing at least 2,200 people and injuring 12,200 amid generalized poverty” [8]. Given this general overview of health challenges faced in Haiti, we now turn to Cholera, malnutrition, and violence-- each of which pose significant health issues for Haiti’s children.

Cholera

Cholera came to Haiti in two waves. The first was during the country’s difficult response to the destruction caused by four hurricanes of 2008 storm season [2]. In addition, Haiti experienced a 7.0 earthquake followed by 52 strong aftershocks. Cumulative damage of the hurricanes and earthquakes was massive. Coping by the crumbling government and other Haitian institutions alone was not possible without the help of the UN and international NGOs. Cholera came with one peace keeping military unit and spread rapidly across the island. Between 2010 and 2019, a total of 820,000 cases of cholera including 9,792 deaths were reported. Children were also severely affected; they made up the largest demographic group infected. The World Bank reports that in 2012 alone, children under 5 had a mortality rate of 87 per 1,000 live births; this was three times the regional rate. The children from the poorest households had a mortality rate more than double the rate of children from the most affluent households [9].

The second wave of cholera cases was identified in 2022—three years after professionals had proclaimed that the first wave was over. The following months 20,000 cases were reported throughout Haiti [10]. The causes of this outbreak are often attributed to societal unrest, institutional instability, and uncontrolled youth gangs [11]. By January there were 2,940 suspected cholera cases reported. Approximately 55.4% of all cholera cases were children under 5 years of age.

Malnutrition

Malnutrition is a very serious problem in Haitiapproximately half of Haiti’s population is unable to meet its minimal caloric requirements. Food insecurity is a result from several factors including poverty, inadequate food production, natural disasters of storms, earthquakes, floods, and their sequelae. In an international comparison, Haiti is related low (104th out of 107) on the Global Hunger Index. This composite measure is based on four characteristics:
1. percentage of the population that is undernourished,
2. percentage of children under five years old who suffer from wasting (low weight-for-height),
3. percentage of children under five years old who suffer from stunting, and,
4. percentage of the children who die before the age of five (child mortality).

Infant and child feeding practices may also contribute to malnutrition. Through the lack of sanitary procedures viruses and unwholesome elements may be passed along. Poverty is also a persistent factor in malnutrition; Haiti has been coping with an economic crisis that has further stressed those at the bottom. In sum, the United Nations has observed: “An unrelenting series of crises has trapped vulnerable Haitians in a cycle of growing desperation, without access to food, fuel, markets, jobs and public services…” [12].

Violence

Haiti has a long history of violence, but it is unprecedentedly acute at the current time [13]. The country is characterized by a societal-wide political power vacuum and instability of social control with the central government not functioning in a meaningful way. The void has been filled by at least 100 violent gangs who control major highways, the distribution of electricity and water, and bus services. Gang violence has closed hospitals and schools and driven an estimated 155,000 people from their homes in the nation’s capital. As the UN The High Commissioner for Human Rights, Michelle Bachelet, has summed up the situation, “Armed violence has reached unimaginable and intolerable levels in Haiti” [14].

Women and children have become specific targets of the violent gangs [15]. For example, recently armed gang members broke into orphanage and raped the women— two 13 and 14 aged young women and another 27-year-old woman. It is reported by observers that the 36 children who witnessed the attacked were traumatized [15]. Children are recruited into the gangs. They are used to engage in sabotage, carry message, and kidnap victims. Some of the children work their way into leadership positions [16].

Cumulative Chronic Stress and Haiti Children

As the preceding sections show, Haiti is a society plagued with several forms of potential and chronic stressors for both adults and children. Mental health professional has observed, “We are exposed all the time to different types of traumata…Mental illness in Haiti exists on a large scale, and because of the worsening situation, the need for care continues to grow.” [17]. Several studies of youth show that many of the experiences of living and growing in Haiti expose them as well adults to stressors such as earthquakes, hurricanes, poverty, medical issues such as malnutrition and cholera, housing issues, violence and gang behaviour and many others as well. Stressors manifest themselves for the children and young adults as PTSD, depression, anxiety, and other mental health problems [18]. Minimal assistance for these issues exists, and vastly more are needed.

Concluding Remarks

Haiti’s problem list” is almost endless. The devastation from cholera is just one of these. According to international health observers, the world is facing a new set of rounds of cholera [19]. To deal with this, public health agencies of surveillance must quickly identify such outbreaks and their potential hot spots. Minimizing any outbreak requires substantial investment in water, sanitation, and hygiene. Haiti now has experience with two invasions of cholera; consequently, its surveillance system may be better able to handle such a forthcoming cholera event; but given the general state of disorganization, that cannot be assumed. Since Haiti must be prepared to fight the other problems discussed above it will need a more organized and functioning government than it has now. It will also require substantial guidance and help from its neighbouring states and the international bodies and organizations.

Acknowledgment

Patricia M. Schwirian, PhD, RN, MPH.

Conflict of Interest

None.

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