1. On Suffering and Structural Violence: The Case of Haiti Cate Oswald, MPH Partners In Health

4. Life expectancy at birth –52 years for men –53 years for women Poorest country in the W. Hemisphere Highest HIV prevalence in the W. Hemisphere

5. Vital statistics Population9.6 million 330 Infant mortality (per 1,000 live births)54 7 Under 5 Child mortality (per 1,000 live births)72 8 Maternal mortality (per 100,000 live births)630 8 Births attended by skilled health staff24.2 % 99% Literacy rate52.9 % 99% Population using improved water resources54 % 99% Population w/ access to adequate sanitation facilities 30 % 98% Population with access to essential drugs0-49 % 98% Children underweight for age (% under age 5)28% 1% National health expenditure per capitaUS $84 US$ 6,714 National health expenditure (public) as % of GDP7.5 % 15.3% CIA World Factbook 2007; UNICEF State of the World’s Children 2008; WHO World Health Report 2008

6. Human Development Index (HDI) Combines 3 dimensions to create index: –Life expectancy at birth, as an index of population health and longevity –Knowledge and education, as measured by the adult literacy rate and the combined primary, secondary, and tertiary gross enrollment ratio –Standard of living, as indicated by the gross domestic product per capita

7. Human Development Index ranking: Haiti ranked 149th of the 180 countries indexed in 2009 Source: UNDP 2006

8. US ranks 13 out 180 Top 10: Norway, Australia, Iceland, Canada, Ireland, Netherlands, Sweden, France, Switzerland, Japan

14. History 1492: Columbus lands on Hispaniola, viewed as the richest country in the New World. Enslavement, harsh treatment, and epidemic diseases decimate the indigenous population 1517-1791: Spanish colonists begin importing African slaves to Hispaniola. The French gain control over the area of Hispaniola that is now Haiti, exploiting social, economic, and environmental resources

15. 1791-1804: A slave rebellion spreads through Haiti. The rebellion endures, despite the brutal French resistance. The loss forces France to sell the Louisiana Purchase to the US 1804: Haitian independence. Haiti becomes the only nation born of a successful slave revolt and the first black republic in the world.

16. 1825: Following two decades of embargoes, France forces Haitians to pay today’s equivalent of US $21 billion for their independence. Haiti is left crippled. 1957-1971: President “Papa Doc” Duvalier establishes an oppressive regime, destroying human, political and economic rights across the country. “Baby Doc” Duvalier succeeds his father and Haiti becomes the poorest country in the Western Hemisphere

17. Haitian Constitution of 1804 Tout Moun Se Moun –(recognizes blacks and whites as free and equal in land ownership, rights, etc)

18. US/Haiti Relations 1915-1934: US military occupation –Imposed written constitution, compulsory labor, centralization of government and industry to cities, created national guard 1978: Killing of all Haitian pigs due to fear of African Swine Fever infecting US pork industry 1980s: Haitians listed as 1 of 4 risk groups for newly discovered AIDS virus by CDC

19. 1986: “Baby Doc” flees as military juntas take over Haiti. 1990: Jean-Bertrand Aristide becomes Haiti’s first democratically elected president. 1991: Aristide is ousted in a military coup. Thousands are killed. 1994: Aristide is restored to power by US-led UN forces 1995: Rene Preval succeeds Aristide. Political upheaval ensues, delaying badly needed foreign aid.

20. 2000: Aristide is relected president with over 90% of the vote. Yet, disputed parliamentary elections serve as a pretense for continued delays in foreign aid. 2001: The US blocks $146 million in approved foreign loans to Haiti. 2004: Democratically elected president Aristide is forced from power and the country on February 29. The US installs an interim government sparking violence and civil unrest. 2006: Preval is re-elected president 2008: “Lavi che”—political unrest due to high costs of food and fuel

21. Haiti’s “Natural” Disaster On January 12, 2010 a 7.0 earthquake hit Haiti The Epicenter was 16 miles outside of Port au Prince Dead: ~300,000 (1 in 10 affected) Injured: >300,000—mostly orthopedic and neurological/surgical Displaced: ~1.7 million

23. Challenges: Delivery of Care Post-earthquake Communication Cataloging/prioritizing cases with no medical history Coordinating & transporting volunteers Continuing to treat chronic disease

24. PIH Structure Enabled Fast & Rooted Response Patient Health System Home Health Professional Community

25. Partners In Health’s Response to Acute Needs:

26. Capacitate Operating Rooms Need for facilities & field sites

27. Create Mobile Clinics  Perform case finding  Address poor access to care  Outreach by community= faster response

28. PIH Response to Chronic Needs:

29. Invest in local economy through response to long-term medical needs: Physical therapy clinics Prosthetics manufacturing Locally produced nutritional supplements Employment of youth leaders and community health workers

30. Public Sector

31. Beyond the Clinic Walls

32. Community Approach as a Platform

33.  Urban/Rural Migration: 1.2  2 - 3 Million  Hundreds of thousands in IDP camps  Physical infrastructure  Sustainable housing with social & medical support Current Challenges: Resettlement

34. Rehabilitation and Mental Health

35. Are people sick because they are poor or are they poor because they are sick?

36. “A Worker’s Speech to a Doctor” When we come to you Our rags are torn off us And you listen all over our naked body. As to the cause of our illness One glace at our rags would Tell you more. It is the same cause that wears out our bodies and our clothes. The pain in our shoulder comes You say, from the damp; and this is also the reason For the stain on the wall of our flat. So tell us: Where does the damp come from? -Bertolt Brecht

37. HIV prevalence (Worldmapper Poster 227)

38. STRUCTURAL VIOLENCE AND CONSTRAINED AGENCY  Neither culture nor pure individual will is at fault for the spread of AIDS.  It is historical context driven by economic forces and processes that has shaped the HIV/AIDS epidemic.  Individual vulnerability, to AIDS is frequently determined by larger socio-economic processes such as gender inequality and short and long- term access to and control of resources.

39. SOCIAL DISEASES = Diseases with a direct correlation Between vulnerability/incidence and low socio-economic status REQUIRE SOCIAL SOLUTIONS

40. Pragmatic solidarity is different from, but nourished by, solidarity — the desire to make common cause with those in need. Solidarity itself is a precious thing: people enduring great hardship often remark that they are grateful for the prayers and good wishes of fellow human beings. But when sentiment is accompanied by the goods and services that might diminish unjust hardship, surely it is enriched. Pragmatic Solidarity

41. “Massive poverty and obscene inequality are such terrible scourges of our times… that they have to rank alongside slavery and apartheid as social ills… like slavery and apartheid, poverty is not natural. It is man-made, and it can be overcome and eradicated by the actions of human beings. Nelson Mandela, 2005

42. What can YOU do to help? –Remain informed about the situation in Haiti and educate your peers –Submit Op-ed pieces to newspapers –Organize and participate in public demonstrations and rallies –Provide financial support for the work of Partners In Health and similar service organizations –TAKE ACTION! Get involved in your local communities on issues of health and social justice

43. Where do YOU fit in? Raise awareness Remain informed about the situation in Haiti and educate your peers Building a movement –Submit Op-ed pieces to newspapers –Organize and participate in public demonstrations and rallies Volunteer (FaceAIDS, ONE, GHC, etc.) Internships Social Networking (Twitter/Facebook/PIH) Provide financial support for the work of Partners In Health and similar service organizations

44. University Students/Groups and Grads Youth Groups and Mentors Solidarity Community PIH Network Chicago New York City Boston Washington DC Miami South Carolina Knoxville Connecticut Virginia COMMUNITIES OF CONCERN San Francisco/ Bay Area