Haiti is located in the Caribbean, on the western third of the island of Hispaniola. The eastern part of the island is occupied by the Dominican Republic. The terrain is very mountainous. Haiti has a very long coastline for a small country and like its Caribbean neighbours Haiti has kilometers of fine beach. Stunning vistas of tropical mountains falling into the sea are typical of the Haitian coast.
The population is currently 8.1 million. Demographics: 95% African, 5% mulatto. Capital: Port-au-Prince (pop. 2 million). The official languages are Hatian Creole and French, but only a small portion of the population (estimated at 10%) speaks the latter. Most Haitians report their religion as either Catholic or Protestant, but traditional African (Vodou) beliefs remain very strong.
Through the 1700’s the area was a profitable French colony, producing an abundance of cash crops for export. Human resource issues in these labour-intensive operations were solved by slavery, with thousands of people captured from West Africa and forcibly shipped to plantations on what is now Haiti. Beginning in 1791 and culminating in 1804 these very slaves contributed to history’s only successful slave revolt and won independence for Haiti. Since independence domestic and international factors have contributed to a string of oppressive dictators and irresponsible governments. Mass exoduses of citizens fleeing poverty and human rights abuses, severe environmental degradation and natural disasters have dominated recent history.
The majority of economic activity is informal (i.e. market vendors, peasant farmers and domestic servants). Unemployment (i.e. lack of formal job) is estimated at ‘greater than 2/3 of the population.’ There is some export of agricultural and manufacturing goods, but in all reality the biggest export has been human; the Diaspora (Haitians living abroad) now numbers in the millions. Remittances from abroad to Haitian families now accounts for 8.3% of current household earnings in Haiti.
Population Health
The prominence of the informal economy makes it difficult to measure economic activity. Some groups have tried; the WHO estimates that 55% of Haitians live on under $1/day. Whether scientific or anecdotal, all conclusions have been similar: most Haitians are extremely poor. The majority of the population (62%) lives in rural areas, yet in the cities there are dense shantytowns of urban squalor. Roads are few and poorly paved making transportation extremely difficult and often dangerous. Forty-nine percent (49%) of the population falls below the minimum level of dietary energy consumption and only 46% has access to clean water. Adult literacy is approximately 52%.
Health Care System
Like many things in Haiti, simple questions are complex and situations are not exactly as they seem. Effectively, health care in Haiti is 3-tiered with some rather unusual nuances.
There is a public health “system” where all treatments are free. Ironically and painfully, however, free treatment does not guarantee care, as any required materials need to be purchased by the patient. If the person in need of care requires medication, gauze, an internal fixator and screws, crutches, whatever, they are given a prescription and the family will then try to find the given article and money to pay for it. If they are not able to do both, the person will remain untreated. Public facilities are chronically under-funded, mismanaged and tragically dirty. Employees are often on strike shutting down facilities. Unusual circumstances often cripple relatively new equipment (most likely sabotage). Public hospitals are present in urban areas and clinics have been built in the countryside, but many of the rural clinics have long been abandoned.
For those who can pay there are various hospitals and medical services that operate on a for-profit basis. Care given at these facilities is normally decent and they are normally well staffed and clean. Unfortunately these services are concentrated in the capital and rather expensive, effectively making them geographically and financially inaccessible for most of the population.
Haiti’s affluent and elite rarely access medical services in the country, this population is more likely to jump on a plane for the 90-minute flight to Miami for any medical needs. This trend effectively creates the top tier of health care “in Haiti.”
Amongst this wide spectrum of service (or lack thereof) there exist two interesting phenomena. For practical as well as spiritual reasons, the initial contact when they are sick is with traditional medicine. Vodou priests and priestesses often double as spiritual healers. There are varying reports as to the practice and effectiveness of traditional healing, and really, it all depends on who or what one believes. The second interesting nuance of health care in Haiti is that of international NGOs. High quality medical facilities have been built in some of the most remote corners of the country by humanitarian and religious organizations offering good care for little or no cost. The organizations are inevitably financed from abroad and often host foreign volunteers for medical work.
Disability and Rehabilitation
To date, the best summary of rehabilitation in Haiti that I’ve seen has been written by Erik Jacobson for the Center for International Rehabilitation Research Information and Exchange (CIRRIE) and is available on their website at http://cirrie.buffalo.edu/monographs/haiti.pdf. It is becoming out of date (2003), but offers an excellent perspective on many issues with disability and rehab in Haiti.
Since a detailed work of good quality is available, I’ll keep my contribution relatively brief. Physical disability is an enormous issue in Haiti. Shoddy medical treatments create significant impairments from minor ailments. Accessibility, as we know it in North America, does not exist. Children with disabilities are often abandoned or neglected as they are seen as consumers of precious resources who can contribute little themselves. Orphanages are very common and over-represented by children with disabilities who were abandoned by their families.
On a happier note, there are some grassroots initiatives looking to promote equality as well as social and physical accessibility for people with disabilities. In Haiti we occasionally see determined individuals who have been creative and persistent and not allowed their disability to prevent them from leading full lives, often without having a role model or any organized support of any kind.
Rehabilitation professions are practically non-existent in Haiti. In Port-au-Prince there are some institutions with signs advertising “physiothérapie” but a patient presenting at such a clinic is likely to receive a back rub or have a free weight put in his hand, all after paying rather dearly for the treatment. My guess is that there are 5 Haitians working in country with qualifications close to that of the international standard for PT, but I have no evidence to prove this. I spent a year hoping to network with local PTs, but met none. Occupational therapy, speech language pathology etc are even less well known than physiotherapy and are not represented in any manner. Medical treatments very rarely include any functional component or consideration.
Haiti is surprisingly close to North America. The short travel time, along with a fascinating culture and ongoing poverty draw many volunteers to Haiti from Canada and the USA, including rehabilitation professionals. Foreign physios, OTs, and SLPs volunteer with many different hospitals and NGOs. Generally, however, the commitment is very short-term (1-2 weeks) and as such sustainable efforts to establish rehabilitation by foreigners are progressed at a very slow pace.
Personal Experience
I have been to Haiti on 2 occasions, for 6 weeks in summer 2003 and for 1-year, between September 2004 and August 2005. On both occasions I worked for the Healing Hands for Haiti Foundation (www.healinghandsforhaiti.org). Healing Hands is an independent NGO dedicated to fostering the expansion and quality of rehabilitation services for the benefit of physically disabled adults and children in Haiti. The foundation’s projects include:
A rehabilitation clinic in Port-au-Prince (including prosthetics, orthotics, therapy gym, medical consults and psychology)
A 9-month training program for rehabilitation aides (very basic PT, OT, SLP and rehab nursing skills)
An education coordination and integration program for children with disabilities
Special projects including outreach clinics, equipment distribution and technical support
The organization is funded through private donations, sponsorships, fundraisers and grants. Healing Hands recruits volunteer rehab professionals as part of medical teams (1-2 weeks), educators (2-12 weeks), or as part of special initiatives (more than 6 months). Most volunteers complement their work in Haiti with some level of ongoing volunteer work in North America. Interested individuals should contact the organization at .
My initial trip was as a rehabilitation aide clinical instructor. In this role I would work with groups of 3 students per day in the orthopedics department of the State University Hospital. Patients were admitted to orthopedics after trauma, most notably motor vehicle accidents and falls. Most patients had multiple or severe fractures or amputations. Occasionally fractures were treated with open reduction and external fixation, but the standard treatment was 6-weeks of traction followed by long-leg casting. Each student would work with a small caseload of patients in order to maintain strength and ROM and promote functional activities where possible.
This first experience with Haiti was a good opportunity to become acquainted with other PTs working in Haiti and was a taste of some of the countless challenges faced in rehabilitation, medical care and volunteer work. In all, however, I found that 6-weeks created more questions than answers and left a yearning to address other issues. By the time I returned to Canada I had already begun planning a return visit…
My second trip was a special initiative financed by Help the Aged Canada. My primary responsibility was to follow up with the graduates of the rehabilitation aide program. During my first 4-months I was able to touch base with 29 of the program’s 46 graduates in order to determine employment statistics. I observed the practice of those who were working to identify trends. From this information I was able to draft a report that was a key resource in the 2005 rehabilitation aide curriculum review.
Besides this main project, I also devoted a portion of my time to orienting and working with medical teams and communication between current and potential volunteers in North America. Flexibility is a necessity for work in Haiti. For parts of the year the security situation in the country did not allow travel around the city. During these times I had to cancel visits to observe graduate practice and worked in the clinic seeing patients and continuing education initiatives with the employees. When heightened travel warnings caused volunteers to cancel their trips, I taught as both a clinical instructor and a classroom instructor for the rehab aide program. When the situation allowed it, I was able to visit numerous hospitals and NGOs to better understand their initiatives and to build contacts and awareness for the future integration of rehabilitation.
A one-year term was a much better opportunity to get a handle on the situation of rehabilitation and medical initiatives. This amount of time allowed for more flexibility (scheduling is DIFFICULT, and repeated rescheduling is a necessity), the chance to see some projects through to completion and some insights into reasons why some initiatives aren’t successful.
Recommendations
Although rehabilitation is not very well advanced in Haiti, there are windows of opportunity. The proximity to North America allows for regular coverage by rehabilitation professionals from Canada and the US who wish to advance the state of physiotherapy from both the clinical and educational aspects. Traditionally, these efforts have been isolated and fragmented. In the final months of my most recent assignment, I connected with Anne Chan, PT, of Richmond, Virginia, USA. Since that time the two of us have been working together to increase communication and participation of physiotherapists working in Haiti. The initial step was the creation of a database for physiotherapists who have worked or are interested in working in Haiti. By October 2005 over 100 names had been collected. The main focus of our efforts is a website with descriptions of work being done in Haiti, a message board and links. This site was launched in June 2006 and is available at:
Haiti can be an extremely difficult place to work. The poverty appears limitless. There appears to be a constant sense of disorder. Social inequality and injustice are rampant. At the same time, it is an absolutely stunningly beautiful country with a rich culture and wonderful people. These latter aspects are what draw foreigners to Haiti and cause us to fall in love with the country. Nonetheless, the former aspects can not be forgotten. These frustrations can be disheartening, but must be remembered to keep all initiatives in context. There is a need for rehabilitation in Haiti, but there is also a need for clean water, nutrition, justice and equality for all the nation’s people, including those with disabilities.
