Still Fissured: Haiti’s Health System, Five Years After the Earthquake
By Allyn GaestelJanuary 12, 2015
Reporting from Port-au-Prince, Haiti
SPARKLING WHITE WALLS, palm trees, and a gazebo paint a serene mask on the hospital in Gressier, an oceanfront town 22 kilometers south of the Haitian capital, Port-au-Prince.
“At first look you see it’s beautiful,” said Vaudrise Paul, a 31-year-old midwife in charge of the maternity ward. “But if you come in, you see it’s so small, there’s no equipment, there’s no staff.”
The hospital is five years old, built after the powerful earthquake that rocked Haiti on January 12, 2010. In the aftermath, charities and nonprofits rushed to Haiti’s aid in an expensive and broadly disappointing relief effort. I went to Gressier in May at the suggestion of Dr. Reynold Grand Pierre, Director of Family Health at the Ministry of Health. I was exploring new programs to improve maternal care; Pierre had spoken with such vitriol about the broken, disjointed system of healthcare that both depended on and was destroyed by the global charity sector. He told me Gressier was an understaffed mess, but when I arrived it felt serene and perfect, cooled with sea breezes from the beach down the road.
As I entered the verdant grounds, I wondered if the minister had been sending me on a goose chase to undermine my reporting. I shouldn’t have doubted though.
In the aftermath of the earthquake there have been countless picturesque projects on this gorgeous Caribbean island — shells of schools with no teachers, gleaming new hospitals with no staff. Many charities have come and gone, and even those that stay largely have short-term contracts. My motorcycle driver, Junior, told me his wife had birthed each of her three children since the earthquake in a different clinic — following a word-of-mouth network about ever-shifting programs and projects to find affordable options for her deliveries. The strings of these myriad distinct programs do not knit into a safety net for Haiti, and mothers are left to advocate for themselves.
Paul was the only midwife in Gressier, in a clinic that saw around 40 births per month, she said. There were four nurses who also handled deliveries.
The labor room had one station. The compact ward was crammed with 8 beds; almost all were occupied.
The maternity ward — called a Basic Obstetric and New Born Urgent Care, or SONUB by its French acronym — is the backbone of the new government plan to reduce Haiti’s devastating maternal death rate. With 350 deaths per 100,000 live births, Haiti is ranked the 10th worst place to be a mother by Save the Children, hovering between notorious countries like South Sudan and Afghanistan.
The SONUB maternities are run by midwives who can handle most normal births and can recognize and refer the 15 percent of women who have complications. Midwives are faster and cheaper to train than doctors, and they are reputed to provide more personal, less medicalized care, something the government hopes will draw more women to the centers. Currently only 36 percent of births happen in institutions, according to government figures.
But the problem with pinning the country’s maternal health structure on midwives is that there are barely any midwives in Haiti — just 201 in a country of 10 million, according to The State of the World’s Midwives, a UNFPA report, at least half of which are in the capital.
And while the SONUBs are government programs, most Haitian midwives would rather not work for the government; clinics are underfunded and staff salaries stagnant. Instead, many work for better-paid non-governmental organizations, some of which offer better care, but almost all of which have short-terms projects that turn Haiti’s maternal health system into a messy patchwork.
“Most of our midwives are in NGOs, not in the state,” explained Grand Pierre of the Ministry of Health.
Many NGOs work on a three-year cycle, leaving families like Junior’s constantly searching for the latest option. The World Health Organization funded a project in 2008 that eventually guaranteed free maternity services in 71 clinics. Maternity wards flooded; overwhelming numbers of women rushed to hospitals. Some gave birth on the floor.
It was replaced in 2011 with a free maternal care project in 18 hospitals. That program ended last November; now free care is even harder to find.
“Free births are in the policy, but there is no budget for it,” Grand Pierre complained.
The latest plan is to have 108 SONUBs in the country, but only 60 were somewhat functional last year, and many of those don’t even have midwives — the pillar of the program.
To meet the need for midwives, the government with UNFPA built a temporary campus for the country’s sole midwifery school, which was damaged in the 2010 earthquake. A new track for high school graduates started last fall, but the first class won’t graduate for three years.
Keeping graduates in government clinics will be a challenge. The midwifery school director estimates one-third of midwives leave the country — of those who stay, many opt for short-term stints at NGOs.
“That’s always the problem with projects […] it’s always fragmented,” Grand Pierre said.
But with Haiti’s budgetary problems — “the state coffers are empty,” President Michel Martelly declared last year — the government cannot refuse the NGOs, even if they provide temporary band-aids.
Paul, like many midwives, has worked in a different clinic almost every year since graduating from midwifery school in 2008.
In Gressier she was paid the “very thin” state salary, around $500 per month. “I can’t live with this at all,” she said.
She earned more than double that when she worked for Médecins Sans Frontières, but she had to find a new job when that maternity shut down.
“NGOs never stay,” she said simply.
Back in Port-au-Prince, another gleaming, new maternity was constructed last year by UNFPA in partnership with the ministry of health. It is tucked behind a government health clinic that, like most health centers, is pressed with people scrambling for care. But the maternity is calmer, there are plants in the courtyard; the midwives that run the facility encourage women to stroll to naturally speed labor.
In the post-partum room 10 white beds are glowingly fresh. Mercy Vierge, 46, lay next to her new baby, born the night before. She reclined with her back toward a flat-screen TV at the opposite end of the ward. A stream of educational videos blared on loop from speakers plastered with UNFPA stickers.
“Everything, everything is UNFPA,” said Amoin Soulemane, the project’s shrill Ivoirian supervisor. Here everything is free, including all necessary medicines. Women are even given a goody bag of baby blankets, soap, and diapers when they come in for their postnatal checkup.
“They say it’s too beautiful to be free,” Soulemane said proudly.
The first month the maternity had 15 births; now they average 80.
Soulemane, the supervisor, had no idea when the project would end. Her contract is annual and renewable, she said; maybe the program would end this year. The clinic is funded through 2016, after which plans for it are unclear.
This is one of four “model” maternities; Joan Lysias, Program Coordinator at UNFPA Haiti said, optimistically, “At the sites you can see a bit the future.”
Paul had a more pessimistic analysis of projects like this one. “They come, put in the structure, save lots of people but then they leave and it’s worse than before.”
“There’s a lot of construction of hospitals. You have the shells but it’s very hard to find the staff,” said Oliver Schulz, country director of MSF Holland. Haiti has 10 percent of its necessary maternal health workforce, according to UNFPA. There are only 400 obstetricians and gynecologists in the country.
MSF has the reputation of providing excellent care, but it focuses on humanitarian emergencies. Though the disaster was five years ago, Schulz says drawing down the project will take time. “You can see, women still don’t have access to healthcare and specialized maternity care.”
But already, an MSF hospital in Leogane, near the Maternity in Gressier — which once had 400 births per month — is winding down.
“I’m wondering what will happen when MSF Leogane closes,” Paul said. There is one private hospital in Leogane that can handle deliveries, “but it’s too expensive for people. They’re going to return to matronnes and houngans,” she said, referring to traditional birth attendants and vodou healers.
In Gressier, the tranquil facade is crumbling. The hospital director said 70 percent of hospital expenses were paid by the Red Cross, but those funds expired at the end of 2014. Funding for the midwife was pulled in September, and Paul left; now only nurses attend deliveries.
Months later the hospital director was transferred to a remote health center in the mountains of Leogane accessible only by motorcycle that has neither staff, nor facilities for deliveries.
Even before she lost her job, Paul foresaw the disintegration of women’s health services in Gressier. “You will see, everything will fall on the back of the state, and the state coffers are empty, to quote our president,” she said.
"Haiti: Then and Now" by Allison Shelley
A woman strings a curtain over the doorway of a small store selling food items at a tent camp in the parking lot of Sylvio Cator soccer stadium in downtown Port-au-Prince, Haiti, April 8, 2011. At the time, camp residents were being asked to leave so that the stadium grounds could be fully used for upcoming events. ©Allison Shelley
A taptap, one of the ubiquitous, unofficial city buses, sits in the parking lot of Sylvio Cator soccer stadium in downtown Port-au-Prince, Haiti, January 3, 2015. For months afterward, the stadium parking lot and field became home to many who were displaced by the 2010 quake. ©Allison Shelley
Men clear debris from the site of the collapsed Notre dame du Perpetuel Secours Catholic church in the Bel Air neighborhood of Port-au-Prince, Haiti, Friday, February 27, 2010. In the harbor is the US hospital ship, the U.S.N.S. Comfort. ©Allison Shelley
A Christmas banner hangs over a road in the Bel Air neighborhood of Port-au-Prince, Haiti, as seen from the grounds of Notre dame du Perpetuel Secours Catholic church, January 4, 2015. Behind is the city port, which was severely handicapped in 2010 quake. ©Allison Shelley
A crowd stands outside at the entrance to a Automecca tent camp, an area where USAID kits containing plastic sheets and wool blankets are being handed out to people displaced by the January 12 earthquake. The camp is estimated to have 15,000 residents. Port-au-Prince, Haiti, Wednesday, March 3, 2010. ©Allison Shelley
Painter Bertony Mezil touches up the fence at the Automeca vehicle dealership in Port-au-Prince, Haiti, January 5, 2015. The hilly back lot of the business was taken over by displaced quake victims, quickly becoming a crowded tent camp. Bertony himself lived in a tent camp in another part of town for an entire year after the house he was renting in the Delmas neighborhood was destroyed in the disaster. ©Allison Shelley
A vendor sells wares in front of buildings destroyed in the January 12 earthquake in downtown Port-au-Prince, Haiti, Wednesday, March 31, 2010. Much of downtown was heavily damaged in the earthquake and many businesses have moved their operation to the street. ©Allison Shelley
Vendors sell their wares in front of a block in downtown Port-au-Prince, Haiti, that was nearly completely leveled in the 2010 quake, January 4, 2015. Five years later, much of the former downtown commerce has relocated to other parts of town. ©Allison Shelley
A water tank in a tent camp behind the Notre Dame de l'Assomption Catholic church sports a message from its inhabitants, in Port au Prince, Haiti, Friday, February 26, 2010. ©Allison Shelley
Five years after the quake, a tent camp behind the Notre Dame de l'Assomption Catholic church still houses the displaced, in Port-au-Prince, Haiti, January 4, 2015. ©Allison Shelley
A statue from a holiday creche display peeks out from the remains of the Sacre Coeur Catholic church in Port-au-Prince, Haiti, Friday, February 28, 2010. The church was ruined in the January 12 earthquake. ©Allison Shelley
Five years after the 2010 quake, a holiday creche at the Sacre Coeur church features character statues, some of which were rescued from the destroyed church. Parishoners worship in a temporary structure as plans are finalized for a new permanent building. ©Allison Shelley
A man stands on wreckage in the hilltop neighborhood of Fort National in Port-au-Prince, Haiti, Sunday, February 28, 2010. The neighborhood was one of the hardest hit in the city and still has not received even the most basic of services, including food, water or tents. ©Allison Shelley
Serge Duchatelier and his wife Gladys Pierre rest on the roof of their home in the Fort National neighborhood of Port-au-Prince, Haiti, January 3, 2015. Serge was feeding the chickens here on the roof when the quake happened. His house stood, but, says Duchatelier, "I watched my neighbor's house disappear and was terrified." ©Allison Shelley
A men's suit coat and women's white dress hang on the front door to the destroyed Ministry of Economy and Finance in downtown Port au Prince, Haiti, Friday, February 26, 2010. ©Allison Shelley
Graffiti reading "Down with the baron. Long live development," is seen on a construction fence, along with a picture of the replacement Ministry of Economy and Finance, which now stands where the former ministry, destroyed in the 2010 quake, used to be, in Port-au-Prince, Haiti, January 4, 2015. The building was deconstructed brick by brick by local residents who sold the materials to construction companies. The lot behind the fence remains empty. The "baron" refers to President Michel Martelly, who will rule by decree if an agreement with parliament allowing elections does not happen by January 12, the five year anniversary of the quake. ©Allison Shelley
At the former Radio Soleil building in downtown Port au Prince, Haiti, workers dig to salvage items before the rubble is hauled away, Friday, February 26, 2010. The station is run by the Cathedral of Our Lady of the Assumption, the main cathedral in Port-au-Prince, across the street and is said to currently be broadcasting from a van. ©Allison Shelley
Attendees enter a newly constructed worship hall next to Notre Dame de l'Assomption — the main cathedral in Port-au-Prince, Haiti — next to the destroyed building during a Sunday Catholic Mass, January 4, 2015. The original church will be reconstructed, with a modern design by Puerto Rican firm Segundo Cardona and a team of six other architects, which won the contract which was chosen from among 134 proposals. ©Allison Shelley
A woman walks past the Topolino building, one of the main shopping areas in downtown Port-au-Prince, Haiti, Wednesday, March 31, 2010. Much of downtown was heavily damaged in the earthquake and many businesses have moved their operation to the street. ©Allison Shelley
Vendors sell their wares in front of the former Topolino shopping center-- leveled in the 2010 quake-- in downtown Port-au-Prince, Haiti, January 4, 2015. The area remains one of the main shopping areas in downtown Port-au-Prince, and is still called Topolino, but the commerce has moved to the street. ©Allison Shelley
Worshippers participate in a Catholic mass from the debris of the Sacre Coeur Catholic church in Port-au-Prince, Haiti, February 28, 2010. The church was ruined in the January 12 earthquake, and makeshift services are now held outdoors. ©Allison Shelley
Worshippers participate in a Catholic mass at the Sacre Coeur Catholic church in Port-au-Prince, Haiti, January 4, 2015. Parishoners worship in a temporary structure, including an outdoor area, as plans are finalized for a new permanent building. ©Allison Shelley
A woman hangs clothing to sell on the street in downtown Port-au-Prince, Haiti, Wednesday, March 31, 2010. Much of downtown was heavily damaged in the earthquake and many businesses have moved their operation to the street. ©Allison Shelley
A woman hangs clothing to sell on the street in downtown Port-au-Prince, Haiti, January 4, 2015. ©Allison Shelley
A man works to clear debris from the site of the collapsed Notre dame du Perpetuel Secours Catholic church in the Bel Air neighborhood of Port-au-Prince, Haiti, Friday, February 27, 2010. ©Allison Shelley
A man prays in a temporary structure housing the Notre dame du Perpetuel Secous Catholic church, which was destroyed during the 2010 quake, in the Bel Air neighborhood of Port-au-Prince, Haiti, January 3, 2015. ©Allison Shelley
Officials raise the Haitian flag in front of the destroyed national palace in downtown Port-au-Prince, Haiti, before a band plays the national anthem the morning of Friday, February 26, 2010. This ritual happens every morning. The palace was designed in 1912 by Haitian architect Georges H. Baussan. U.S. Naval engineers supervised its completion in 1920. ©Allison Shelley
Officials march away after raising the Haitian flag on the national palace grounds in downtown Port-au-Prince, Haiti, the morning of January 10, 2015. This ritual happens every morning despite the fact that the grounds are now shielded from public view by a large green fence. The demolition and clearance of the destroyed palace was done by the American NGO J/P HRO in 2012. ©Allison Shelley
Sixteen-year-old Fedya sits with other pregnant women in front of the shelter of the local midwife Benite in the La Piste tent camp in Port-au-Prince, Haiti, March 24, 21011. Fedya chose to stay in Port-au-Prince when her family fled the city after the January 2010 earthquake. She lives in a one-room tin hut with a family friend, that friend's husband and the friend's young son. ©Allison Shelley
A man rests in the shade of a small bush on the grounds of the former tent camp known as La Piste, a former military airport, in Port-au-Prince, Haiti, January 10, 2015. The camp held 50,000 displaced at its peak in 2010, but was the target of an IOM resettlement program which began in 2013 and emptied it. ©Allison Shelley
Remains of the state university school of nursing — L’Ecole Nationale des Infirmières de Port au Prince — on the grounds of the general hospital, in downtown Port au Prince, Haiti, Friday, February 26, 2010. An estimated 74 students died in the building. ©Allison Shelley
Nursing students at the state university school of nursing — L’Ecole Nationale des Infirmières de Port au Prince — on the grounds of the general hospital, prepare for classes in temporary trailer classrooms as construction crews work around them to build back the nursing school and hospital which were destroyed in the 2010 quake, in Port-au-Prince, Haiti, January 10, 2015. ©Allison Shelley
This photo essay was supported by the Pulitzer Center.
All photographs by Allison Shelley. All rights reserved.
Allyn Gaestel is a freelance journalist who covers human rights, inequality, gender, global health and the human repercussions of politics. She has worked in West Africa, the Caribbean, and Southeast Asia for outlets including The New York Times, The Washington Post, Al Jazeera, The Los Angeles Times, Reuters, and CNN and has received grants and fellowships from the Pulitzer Center, The International Reporting Project, The National Press Foundation, and others.
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