The Setbacks of the Management of COVID-19 in Haiti

This is the third in a three-part series on COVID and the Caribbean. Read parts one and two here.

by Emmanuel Moïse Yves, Centro de Periodismo Investigativo and AyiboPost

PORT-AU-PRINCE, Haiti — Lack of government resources, cultural beliefs, political turmoil and natural disasters have made it impossible for the ruined Haiti’s healthcare system to adequately respond to and monitor the COVID-19 pandemic, a Centro de Periodismo Investigativo (CPI) report revealed.

Nonetheless, on the ground accounts assure there has not been a death calamity because of COVID-19 in Haiti. The isolation caused by civil unrest, extreme violence and political instability may have —ironically— spared their lives. 

First there were no tests available, only three public COVID-19 clinics available, and private hospitals refused —and still refuse today— to admit COVID-19 patients in this impoverished Caribbean nation of 11 million. But then, authorities saw patients were not arriving in the few available clinics, even though there was an outbreak of undiagnosed fever symptoms among the population. The reason: most people preferred to stay at home using traditional medicine remedies.

Today the death toll and level of contagion are unknown and cannot be estimated since comprehensive mortality statistics do not exist and testing is low. Vaccination is also very slow with less than one percent of the population vaccinated.

Until July, vaccines were not widely available, but since then the country has received 600,000 doses but had to return 250,000 of those doses to donating entities to avoid expiration because of the low demand.

Haiti officially listed its first cases of coronavirus on March 19, 2020. Since then, the number of people tested positive for the COVID-19 virus has continued to increase dramatically. According to the latest assessment of the epidemiological situation of COVID-19 in Haiti, published on November 20, 2021, there have been 25,027 confirmed cases of coronavirus and a total of 727 deaths out of the 139,106 tests that were administered. According to this same report, the rate of positivity was 18.1 percent .

The active spread of the virus in Haiti in June 2020 (which is considered the peak of the disease) affected Marie Claudette Jocelyn, a resident of Saint-Jean-du-Sud in the country’s Sud department. “I had had a huge headache for about three weeks, intensified muscle aches, severe coughs with a terrible fever,” says the 60-year-old farmer. She had refused to be hospitalized and recovered on her own with local herbal teas. Her contamination was confirmed by a daughter-in-law who works at the National Public Health Laboratory.

A team was dispatched by her daughter-in-law to find her in her home, situated remotely in her commune. Otherwise, she may not have known that it was the virus that was affecting her because, at the time, the number of tests performed daily by the Haitian health authorities was very limited. According to the epidemiological report of the Ministry of Public Health and Population (MSPP in French) on June 30, 2020, 12,566 suspected cases of COVID-19 had been tested. 

During the period ranging from January 31 to June 30, 2020, about 2,400 tests per month were conducted over the five month interval.The quantity of tests carried out is very low compared to the Dominican Republic which, with 10.9 million inhabitants, did an average of 19,886 tests per month during this same period. Haiti has just passed 119,319 tests during the month of October 2021, while the neighboring country has done more than two million tests.

“We had to set criteria before we could do tests. The patient should clinically show signs of illness before being tested in order to avoid wasting our resources that we did not have in large quantities since a PCR test costs more than USD$100,” said Dr. Lauré Adrien, director general of the MSPP. “The other problem is that the machines used to perform PCR tests at the time were being used for the management of tuberculosis (TB) and Human Immunodeficiency Virus (HIV). As a result, tests have been performed in small quantities so that people could also continue to be screened for HIV and TB. These kinds of problems already existed.”

Despite their limitations, health measures have been taken to prevent the disease among the Haitian population. However, the already weak Haitian healthcare system had caused real concern among the population in the event of massive contamination. 

“Fear of being infected by the virus had made citizens aggressive towards people who tested positive. Those who were infected with the disease also fear being the victims of the population,” said Dr. Raphaël Allan, a surgeon at Immaculée Conception des Cayes Hospital in the Sud department. 

The reaction of the residents of the city of Milot, in the Nord department, confirms the words of this doctor. To avoid the spread of the virus in their community, residents tried to take the life of Bellamy Nelson, a university professor suspected of contracting the virus. The Bernard Mevs Hospital in Haiti also experienced a similar situation, when people threatened to set fire to the hospital that wanted to set up a COVID-19 treatment center there. 

Despite everything, the 20,000 deaths and three million infected people according to the epidemiological forecast announced by the scientific task force did not take place. According to Marc Edson Augustin, the medical director of St. Luc Hospital in Haiti, these elements contribute to the population’s refusal to be vaccinated against COVID-19. “The coronavirus is still in our walls. Vaccination remains the best way to fight it. But people remain wary of the vaccine as the announced hecatomb has not taken place and the level of contagion remains low in Haiti despite non-compliance with preventative measures by the population,” said the doctor.

Dr. Lunick Santiague is a trauma surgeon and director of the coronavirus treatment center in the Delmas 2 zone. According to him, the violence, lawlessness and instability that has been escalating in Haiti is probably one of the reasons which explains why there are not many COVID-19 cases in the country. 

“The problem of insecurity has forced the diaspora and tourists not to return to Haiti for the end-of-year celebrations of 2019. The insecurity and the deleterious situation of the country at the beginning of 2020 obliges the government to cancel the carnival festivities of February 2020—hence the absence of foreigners and tourism. This is why Haiti may not have recorded too many positive cases and deaths, although it is also known that exact figures in terms of prevalence for the pandemic are lacking in Haiti since the population has not been massively tested,” Dr. Santiague said.

Silent Spread of the Virus

Haiti is currently facing a flurry of coronavirus cases since the announcement by the MSPP that reported on September 16, 2021, the circulation of Delta and Mu variants in the country. “Currently, there is an increase in the number of contaminants in the analysis performed. This observation must be repeated for several weeks in order to conclude that a peak of the disease has been reached,” explains Dr. Jacques Boncy, director of the National Public Health Laboratory.

The current fuel shortage for electric power in Haiti affects the ability of laboratories to perform screening tests. This situation significantly reduces the case monitoring activities that would in fact cause much more cases than the published figures. But before this, there was the political crisis that affected the communication campaigns of the COVID-19. The distrust of the population in political leaders had led them not to believe, in the first moments of the pandemic, that the disease exists in Haiti. These factors, coupled with the August 14 earthquake in the south, prevented the MSPP, whose resources are scarce, to properly monitor the disease in Haiti.

The increase in new cases mentioned by Dr. Boncy is also confirmed in hospitals. St. Luc Hospital, located in the commune of Tabarre, is one of the free community centers in the western region of Haiti to receive people infected with the COVID-19 virus. According to the medical director, Dr. Augustin, St. Luc’s Hospital is experiencing an increase in the number of patients infected with the COVID-19 virus. “There had been a lull for almost three months in the hospital. There are now four times as many people being hospitalized because of COVID-19 complications. Before, the hospital had about twenty patients,” says Dr. Augustin.

The doctor believes that the coronavirus preparedness and response plan developed by the MSPP to counter the pandemic in Haiti was not enough to deal with the severity of the public health emergency they were facing. 

“Despite their low capacity, the Haitian health authorities have made great efforts to deal with the virus. We had put in place a preparedness and response plan for the interventions that should be carried out. On the other hand, if one considers the financial shortcomings facing the Haitian health care system, one can quickly deduce that this plan did not fully address the threat of the disease,“ says Dr. Augustin.

In fact, the Haitian health system has been experiencing serious financial difficulties for years. In the 2018-2019 bill, still in effect as there is no parliament to ratify a new one, only four percent of the national budget is allocated to health. This amount is far from the recommendations of the World Health Organization (WHO) which suggests a 15 percent of the national budget in low-income countries spent on health.  

“This amount represents almost nothing for the Haitian health sector. That said, the Haitian state has not been too concerned about health investments for years. The MSPP authorities could not be expected to perform a miracle during the coronavirus,” said Augustin. 

The director general of the MSPP, Dr. Adrien, mentions both the security and financial problems facing the country that are hampering the actual implementation of this plan. 

“The plans are based on forecasts,” he said.

“In addition to the means, the behavior of individuals in relation to the information disseminated is necessary for its success,” he added. “It is probably on this point that one can probably say that we have lost the battle. Regardless of the degree of awareness, we fail to have the expected response in the population. This kind of case is not specific to Haiti since around the world, there is a set of people who go against established principles and other awareness related to the disease.”

However, the Director General is pleased with the management of the disease, despite the failure of the Haitian health system. “There has not been too much damage and loss of life in Haiti. We are not the only ones with this epidemiological profile, many countries in Africa are experiencing the same,” he remarked. 

With 3,354 doctors for 11 million people according to the latest census of health professionals conducted in 2018, Haiti could not cope with the disease if the country had many people affected by severe forms of the disease. 

The Inactivity of Care Centers

To deal with the coronavirus in Haiti, 1,011 beds were arranged in 26 care centers only for COVID-19 patients. These never overflowed with cases even during the period considered to be the peak of the disease. The centers were created after epidemiological forecasts that predicted about three million people would be infected with the disease and 20,000 could die. 

“The concern of the scientific task force was to prevent too many complicated cases from invading hospitals, which is why the state had taken steps to set up these care centers,” said Dr. Boncy, president of the Scientific Unit created to make proposals to the government on how best to fight the virus in Haiti. 

For Dr. Augustin, COVID-19 has not had time to test the Haitian healthcare system. 

“The anticipated epidemiological scenarios were false. As a result, the centers that were set up to accommodate patients were not filled as planned. Thus, our already failing health care system has never been cracked or overtaken by the epidemic. Besides, most of the people who contracted the virus stayed home,” said Augustin.

During the rise in cases in June 2020, the Canaan care center, which had 200 beds, only got three patients. The care center at the Olympic Center, with 160 beds, only received one patient during this same period. 

“These centers had almost no patients when many cases of coronavirus were identified in Haiti. It is true that not all infected people needed hospitalization, but most of those who needed it refused admission,” explained Dr. Adrien. 

According to the director of the national laboratory, Dr. Boncy, most confirmed cases who had refused hospitalization are explained by the relationship that the Haitians have  with health facilities. 

“Most Haitians don’t like going to the hospital for treatment. It is not part of the culture,” he says.   

According to Dr. Santiage Lunick, director of the Delmas 2 COVID-19 site, the center suspended its COVID-19 activities from August 14, 2021, in order to accommodate the victims of Le Grand Sud earthquake. 

“The few COVID-19 patients we had were transferred to other centers, including St. Luc Hospital,” he says. 

“During this period, the centers were open and had health equipment and personnel assigned to care,” said Dr. Adrien. “These structures were not closed because the state wanted them closed down. The inactivity observed in these centers forced the state to reduce the health staff that was more than the patients admitted. This is how these centers were deactivated. Nevertheless, spaces for COVID-19 units in hospitals still exist. We will activate them when needed,” the Director General said. The centers were deactivated in September 2020.

He also admits that there have been many positive cases in Haiti. The positive cases were probably much more than what the official data reveals, he says. “But the country has had very few patients who have developed severe forms of the disease,” he argued. 

“Besides, Haiti is not the only one to be spared from a health disaster related to COVID-19, the epidemiological scenarios predicted for many countries in Africa and the Caribbean have not taken place,” Dr. Adrien added.

The Questioning of COVID-19 Statistics

Since the appearance of COVID-19 in the world in December 2019, the number of people infected with this virus has continued to grow. According to WHO data, more than 257 million cases of COVID-19 are confirmed worldwide. The figures also show that five million deaths have already been recorded for the pandemic.

According to the recent epidemiological report from the MSPP on November 20, 2021, the coronavirus rates in Haiti show 25,027 confirmed cases (47.2 percent women) with a 2.9 percent fatality rate. Haiti reported only 727 deaths caused by COVID-19 and a total of 20,973 infected people who are already recovering from the disease. At the same time, the western department had nearly three-quarters of its population infected with COVID-19. But the highest lethality rate in the country remains the department of Nippes with 7.84 percent and the department of Nord with 6.18 percent. The number of tests carried out in Haiti is 133,064 for the 11 million inhabitants.  

Professionals working in the Haitian health system are wary of this data shared by the MSPP. To this end, the Director General believes that even if the official figures do not reflect the actual reality, they still reflect a close picture of the epidemiological reality of the country. 

“When a positive case of COVID-19 is found, it is not the only case of contamination,” Dr. Adrien noted. “You can have five or six related cases. One must also consider the behavior of the population in relation to the disease because many are the people who refuse to admit that the disease exists in Haiti. People who have been tested positive for the disease question their diagnosis and refuse to believe they are carrying the virus.”

There is virtually no unofficial data on the disease outside of official figures. In fact, most private hospitals in Haiti had refused to receive COVID-19 patients. According to Dr. Boncy, president of the Scientific Cell Against COVID-19, not all deaths related to COVID-19 are recorded. 

“The balance sheet presented by the MSPP represents the number of institutional deaths reported as all COVID-19 centers were managed by the state. There are other cases outside the [public] hospital system that are not accounted for. I consider this data to be indicators. For example, when they are on the rise over a period of time, I see them as a sign of the severity of coronavirus disease in Haiti,” said Boncy.   

During the peak of the disease in Haiti, there was an epidemic of slight fevers. Many people had been affected by a fever which had symptoms similar to those of the new coronavirus. Dr. Augustin holds that these people were not screened. 

“There were no laboratory tests on these people because of the low testing capacity of the MSPP at the time. In my opinion, it is very likely that this little fever was a moderate form of coronavirus. Given that the Haitian population has a high percentage of young people, relatively healthy, they have all resisted the severe forms of this small fever that is akin to coronavirus,” says Dr. Augustin, whose hospital is actively involved in the fight against coronavirus.

Existing data corroborates Dr. Augustin’s theory because young people are the population least affected by COVID-19. People between the ages of 20 and 49 account for more than two-thirds of contamination cases, according to the October 20, 2021 epidemiological report. However, it is difficult to have reliable data on the demographic profile of the Haitian population.

The Issue of Vaccination

According to figures released by the MSPP, a total of 117,881 doses of vaccine have been administered in Haiti since July 16, 2021, the date of the first injection. As of November 20, 2021, only 66,888 people are fully vaccinated—less than one percent of the country. The population’s contempt for the COVID-19 vaccine slows down the vaccination process and prevents Haitian health authorities from achieving the desired vaccine coverage rate. According to Tristan Rousset, communications officer in the Office of the Pan American Health Organization and the World Health Organization in Haiti, the Haitian government intends to vaccinate 20 percent of the population.

Lambert Santé, a clinic located in the commune of Pétion-Ville, is among the 149 vaccination sites in the country. Vaccination activities were slowing down at this center during the last week of October. 

“We get about 50 people a day,” says one of the nurses there. “The population is not too interested in getting vaccinated against coronavirus.”

These remarks confirm Jones Polycarpe’s observations toward the vaccine. Polycarpe is a student at the State University of Haiti. He said that around the world some doctors do not agree on the effectiveness of vaccines. His opinion is that there is no reason for Haitian health authorities to force people to get vaccinated while the country is only slightly affected by the disease. 

“No one is going to force me to take this vaccine, which is already having adverse effects on some individuals,” he said.

Many people in Haiti share Polycarp’s opinion. The Director General says he is aware of this reality. 

“The vaccine is not mandatory. Tt must be made clear to the public,” says Dr. Adrien. “Nevertheless, people have the right not to accept it but the problem is when these people want to influence the behavior of others.” 

The MSPP is still slow to find the right vaccination strategy in Haiti. Meanwhile, public reluctance is challenging vaccination forecasts in Haiti. 

“If the process went according to plan, the 500,000 doses of Moderna vaccine received in July 2021 would have already been administered well before their expiration,” says the Director General.

The poor record for vaccine coverage forced Haiti to return to the COVAX —a program for global and equitable access to vaccines against COVID-19— more than 250,000 vaccines that would expire on November 6, 2021 and had to be returned to COVAX so they could be reassigned to other countries with high demand.

“Vaccination continues,” says Dr. Adrien. “The Ministry of Health is trying to open many more vaccination sites in order to avoid such a situation with the 100,000 new doses of the Moderna vaccine received on November 4th, 2021.” The 100,000 doses of vaccine received in Haiti through COVAX is five times less than the first vaccine stock delivered in Haiti.

According to sociologist Wenchel Jean Baptiste, also director of the Caramed Hospital in the city of Les Cayes, the Haitian population’s refusal to accept the coronavirus vaccine is explained by its behavior in the face of science. 

“Haitians have not developed a good relationship with science,” he said. 

Since they already assume that vaccines produce harmful effects, no matter what scientific explanations or methods are used to convince them, they remain unconvinced, he explained. Parallely, the Haitian population has not rejected the general benefits of other vaccines. They regularly vaccinate their children through programs managed by MSPP that fight polio, diphtheria and other diseases. These existing programs that encourage Haitians to vaccinate their children are part of the Haitian tradition and family practices, but this does not mean that most Haitians believe in these vaccines having actual effects on their children. 

The opinion of naturopath Patrick Jacques is rather strong on the subject of vaccination against the coronavirus disease. Jacques specializes in naturopathic and internal medicine. He is in charge of spearheading the direction of Traditional Medicine at the MSPP. For him, the strategy should not be alarming people in order to force them to get vaccinated. 

“The population of Haiti develops a kind of collective unity toward the disease,” he suggested. “We don’t need to get vaccinated to fight COVID-19.”

Maxo Noël is a pharmacist, and though he built this reputation as a practitioner of traditional medicine, he believes Haitians should be vaccinated. “The people have to be vaccinated. The traditional medicine might admittedly cure the mutation of coronavirus, I believe the vaccination is needed to boost the immune system.”    

The Contribution of Herbal Teas and Traditional Medicine 

In Haiti traditional medicine is in high demand. According to Jacques, there are 40,000 herbal doctors in the country. After the arrival of coronavirus in Haiti in March 2020, Haitians have for the most part resorted to herbal remedies to prevent and cure the disease in cases of contamination. Haitians are used to drinking tea to cure ailments. That’s why Marie Claudette Jocelyn, mentioned at the beginning of the article, says she only took herbal teas until she was completely cured of the virus.

“Traditional medicine has played a major role in the fight against coronavirus and has allowed us to develop resistance to the disease,” said Jacques. He relates that among the medicinal compounds used there were both preventive remedies (ginger-based teas, sagebrush, and aloe vera) and curative remedies (ginger compounds, milk, and other medicinal leaves). These recipes are sometimes varied according to the region.   

These medicinal compounds, established in the form of a protocol by the Directorate of Traditional Medicine, had received particular attention from the State University of Haiti (UEH). In a study conducted in July 2020, the UEH identified 72 traditional recipes for preventing and combating the disease. The UEH had addressed the issue in order to share a scientific and ethical opinion on the formulas and recipes used. 

“According to the literature consulted and the prepared monographs on the chemical composition and properties of the products used, it can be said that the population has been able to make an appropriate choice of products and that the recipes used can provide a better solution for many symptoms or even prevent the occurrence of complications of the disease, which testifies to the good knowledge of herbal medicine of the population and its particular ability to handle plants,” reads this document.

The MSPP refuses to recognize the effectiveness of these remedies in the fight against the disease, says the head of the MSPP’s Traditional Medicine division.

“In spite of everything, an attempt was made to establish a campaign on community radios and newspapers to encourage the population in this medicinal practice,” says the division head, a traditional herbalist. He believes that the division he leads within the ministry must become an independent entity in order to have the full capacity to truly endorse the benefits of traditional medicine in Haiti and to be able to conduct research in this area.

Noël estimates that traditional herbal recipes contribute to the healing of nearly 80 percent of the country’s COVID-19 infected. Nevertheless, health professionals and health authorities refuse to comment on the role or contribution of traditional medicine in mitigating the health risks associated with the disease. For sociologist Wenchel Jean Baptiste, traditional recipes have played a crucial role. 

“There is also a relationship between mental predisposition and facts. Given that Haitians strongly believed in the effects of traditional medicine, this mental disposition, considered outside of the healing virtues that plants actually have, still positively impacted the expected results,” he explained.

Perspective of Health Experts

Haiti has one of the poorest healthcare systems in the world. Despite the efforts made in recent years, there is no significant improvement in health indicators. Health coverage remains inadequate and inaccessible to low-income citizens which account for nearly eight million of the population, according to data from the United Nations Development Program. Data given at the beginning of the article on the number of doctors available to the Haitian population illustrate this reality. 

“Indeed, the Haitian state had acquired medical equipment to strengthen the medical system during the illness. But the country is so gangrenous with problems that it will be difficult to assess and really see the impact of these efforts,” said Dr. Adrien.

That said, the MSPP Director General believes that Haitian leaders are incapable of changing for the best what they have learned in any area. 

“The issue of health in Haiti is complex, it must be placed in the context of the country’s overall development,” he said. 

Dr. Santiago Lunick agrees. According to him, the governance of Haiti greatly impacts the various institutions of the country. 

“The day the Haitian state performs, all the country’s institutions will function more or less satisfactorily. It is more than obvious that Haiti cannot benefit from a successful health sector in an extremely disorganized country,” he said.

The investigation was possible in part with the support of Para la Naturaleza, Open Society Foundations and Fondation Connaissance et Liberté (FOKAL).