Sexual Health in Post-Disaster Scenarios: Haiti

by Phil Schertz

I visited Haiti in June 2014 as a member of an international medical team lead by Dr William Forgey, the former President of the Wilderness Medical Society. The purpose of our mission was to establish multiple mobile clinics in the town of Verrettes, which is based in the mountainous northern region. Many Haitians had fled to the town to escape the violence and destruction around Port-au-Prince after the earthquake in 2010, which claimed over 220,000 lives and made 1.5 million homeless. Verettes was also close to the epicenter of the Cholera outbreak that ravaged the country shortly after the earthquake and claimed several thousand more lives. Even 5 years later despite the international aid that flowed in, Haiti is still very much recovering with the impact of the earthquake seen almost everywhere we visited. 

After passing through the make shift IDP camps and basic tent shelters scattered around Port-au-Prince, we entered the countryside. Untouched is the best way to describe the land. Necessities such as clean water were difficult to come by due to a breakdown of basic infrastructure and provision of core services such as sanitation was out of reach for most of the population.

In the days that followed we set up mobile clinics in very basic buildings provided by the community, around the town. Anywhere simple wooden chairs could be arranged into circles and make shift tables could be built for the pharmacy, was sufficient for a clinic.

We quickly discovered that one of the greatest medical issues affecting the local population was HIV and sexually transmitted infections [STI]. The problem was both treating the individual and then preventing their recurrence by treating their partner(s). The local community was very appreciative of the need to treat both parties and would often send in their partners for treatment shortly after visiting us. By the third day I even had a husband and wife couple come to the clinic together to receive treatment, so it appeared that our message was getting across.

Our strategy was not always successful, especially in cases involving single men and women who often did not appear to know the identity of their partner or were not keen to identify them. In these cases we would treat the patient accordingly to our protocols, but with this group there was a high risk of recurrence of STIs as well as exposure to HIV. The population often rely on inaccurate information about safe sexual health practices and without condom use, STIs have spread rapidly with an HIV rate in Haiti which is amongst the highest in the Caribbean region.

It was shocking to see a number of under-age children at the clinic with STI infections. Most children end formal education before they reach puberty and there is generally lack of focus on sexual education as well as high levels of exploitation and abuse. Many very young girls we saw had been forced by dire economic circumstances into ‘survival sex’ work. In a country with the unemployment rate for youth females at 20.50%, prostitution is one of the very few available choices for these girls to earn sufficient income to provide for themselves or their families. These girls, some barely teenagers, would always come to our clinics solely to request STI treatment for themselves. With limited resources locally, we relied on clinical history and local disease prevalence to determine the nature of the STI and suggest the appropriate treatment. Up to 30% of women in the region have admitted to entering a sexual relationship for economic gain. It is difficult to comprehend the great dangers these girls face during their work with constant exposure to HIV, STIs, sexual violence, associated mental health and medical issues as well as social stigma and isolation from the community.

Though no patient came to the clinic admitting to have been raped, there is no doubt rape and abuse accounted for some STIs we treated. The local hospital had recently introduced a medical pack for adult female and child victims of sexual assault. This contained valuable medications such as anti-virals to prevent HIV seroconversion, drugs to treat likely concurrent STIs and prevent pregnancy as well as anxiolytics to help with mental distress. Another challenge in stopping sexual violence in the town is the lack of legal repercussions for the rapist. Accountability of any unlawful acts relies on the population for action because there are no more than 5 police officers for a town of 50,000 and corruption is rife. Perhaps just as damaging for the victim is the fact that he/she has no one qualified to provide proper long term medical care and counselling after the assault. If we can train a few of the Haitians locally in some basics of counselling and care for a post rape scenario, it will make a huge improvement in the victims of sexual violence. 

Haiti is a country where STIs run rampant. The WHO estimates in 2006 contraceptive prevalence was only 28.50%. STIs in the Artibonite Valley, where we set up clinics, include in descending order Trichomonas, Chlamydia, Syphilis, Gonorrhea, HIV. 40% of women tested were positive for at least one STI. HIV is estimated to have affect 140,000 Haitians and caused 6,400 deaths. Research suggests that HIV was brought to Haiti around 1966 by a single person; tracing the almost exclusive infection of HIV subgroup B supports the single person hypothesis. The disease spread rapidly with poor sterilization techniques and improper plasma donation sterilization. Exportation of the plasma to The United States is believed to further account for the portal of entry of HIV into the United States.

The STI epidemic in Haiti is exacerbated by a number of factors locally including the poor education the population receives about safe sex and poor access to proper prevention measures and effective treatment. We can only have a temporary impact in the region by treating patients as the only way to make a lasting impact is to promote safe sex education and engage local community workers trained to recognize the signs of STIs, distribute medications, and provide counselling and relief for the victims. 

Other problems with the local medical infrastructure included the lack of medications and scarcity of basic medical equipment including diagnostics. With many newly trained nurses and doctors leaving the country to seek higher pay at the first opportunity post-qualification, there is a dramatic shortage of healthcare professionals in the country. Even the providers that stay face faulty outdated equipment and inaccurate lab tests, low pay and excessive workloads. The local patients tell stories of regularly sitting in the hospital all day to receive medications with many asked to leave mid-afternoon when the clinics close and return to queue the next day all over again.

One area where Haitian medical staff have worked differently with some noticeable impact is the introduction of Haitian leaf healers into the established paramedical fraternity. Leaf healers have provided initial medical treatment and education for those not able to go to a hospital or afford western medicine over centuries and continued to be consulted regularly by the majority of the population. We encountered a number of traditional healers during our trip. They appear to have occupied a middle ground now between the population who still regularly consult within them and the western science based medical teams. Many healers now work in a loose partnership with medical staff from local clinics and hospitals and are happy to refer on the difficult and complex medical cases that present to them. Since the leaf healers are easier and cheaper to access for the locals, as well as enjoying a respected position in the community, they are often used as the first point of contact for most Haitians with a medical issue. Engaging with the leaf healers and training them in basic public health, has therefore been critical in communicating the message about safer sexual health practice and HIV prevention. They were also effectively used both to help manage the Cholera outbreak post-2010 with many administering basic medical treatments and issuing cholera prevention kits. Perhaps working with them to identify and manage the associated issue of GBV could be a practical and effective measure towards tackling the problem longer term. 


Phil Schertz has undertaken two humanitarian aid missions in Haiti where he worked as a part of an international team providing acute medical care and medication to over 1500 patients including victims of sexual violence in the Verrettes commune, which is found in the remote mountainous region of Artibonite. 


References:

Disasters Emergency Committee (2015), Haiti Earthquake Facts and Figures,  Accessed: July 2015

Naturopathic Relief Clinic For Haitian Earthquake Survivors, Homage to a Great Afro-Haitian Traditional Healer, Available at: http://www.haiti.citronica.com/oliama, Accessed: July 2015

Quandl (2015), Haiti Unemployment Data, Available at: https://www.quandl.com/collections/haiti/haiti-unemployment, Accessed: July 2015

Fitzgerald, DW et al (2000), Economic Hardship and Sexually Transmitted Diseases in Haiti’s Rural Artibonite Valley, Am J Trop Med Hyg, Vol.62 (4), pp. 496-501

Quandl (2012), Haiti - Health Data, Available at: https://www.quandl.com/collections/haiti/haiti-health-data, Accessed: July 2015

UNAIDS (2013), Haiti, Available at: http://www.unaids.org/en/regionscountries/countries/haiti, Accessed: July 2015

Mcneil, D. (2011), Chimp to Man to History Books: The Path of AIDS, The New York Times, Available at: http://www.nytimes.com/2011/10/18/health/18aids.html, Accessed: July 2015