L48 Anthro 3283 Chapter Notes - Chapter 6: Improved Water Source, Improved Sanitation, Hisense 4K Tv 300
RGH Ch. 6 Building an Effective Rural Health Delivery Model in Haiti and Rwanda
Haiti: History
• Brutal labor system gave way to the largest slave revolt in history
• First black republic in the world; born in 1804
• In 1881, trade duties made up 98% of state income
• The majority of the population, remains rural smallholder farmers, increasingly excluded
from the power structure of the capital, and continued to be the chief producers of the
country
• The U.S. and most of Europe refused to recognize Haiti until the late 19th century
• The U.S gained much control of Haiti in the 1900s – rewrote their constitution to allow
foreign ownership of land and to open more markets to U.S. investors, concentrating
power in Port-Au-Prince
• From 1804 to the mid 1900s, little infrastructure was built
• Reign of Francois Duvalier intensified the centralization of wealth and power in the
nation’s capital; by the end of it, 80% of the government’s budget was consumed in Port-
Au-Prince, which housed less than 20% of their population
o Electricity, health care and higher education was concentrated there
• Duvalierism – widened the divide between the state and the poor and further undermined
the capacity of the government to provide services for its citizens
o Him and his son were a dictatorship, did nothing good
o The U.S. sponsored them, contributing to their personal wealth and to a system of
state-sponsored terrorism
• Faced an ecological crisis – deforestation → erosion and decreased crop yields; further
pushed into hunger by the unfair trade practices that wiped out their rice production
o Could do little to protect its agriculture
o Hunger riots in 1985
• Baby Doc fled, leaving the power in the Haitian army
• 1990 – first free and fair election led to the presidency of Jean Aristide - supported
peasants and the urban poor
o after 9 months he was forced out of office by a military coup
o came back to presidency with the help of the U.S. and the UN
o strongly supported the poor, policies were designed to benefit the poor majority,
people did not like this
o in 2004, force from office again
Health Care in Haiti
• rural per capita income under $300 per year, on the edge of famine, health problems
worsened by chronic undernutrition
• in 2009, World Bank estimated that only 51% had access to improved water source and
only 10% had access to improved sanitation facilities
o more than half of Haitians lived on less than $1.25 a day, with 58% of children
undernourished, more than half of kids were not in school
• after January 2010 earthquake, health expectancy = 61 years, mortality rates for children
under 5 were 72 per 1,000
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• diarrheal disease effects children of all ages; the leading cause of disease among poorly
nourished preschoolers and the main cause of them missing school
• malaria is still there
• 2006 – physician-to-population ratio was 25 per 100,000 (compared to 256 in the U.S)
• HIV/AIDS brought in the 1970s by tourists
• mid-1990s – prevalence of it increased to 5.6%
Cange
• Partners in Health and its sister organization, Zanmi Lasante, were launched in the mid-
1980s in Haiti’s Central Plateau, with the founding of a small clinic in Cange
• Cange was a squatter settlement of displaced peasant farmers who had lost their land,
homes and their livelihoods when the construction of the Peligre dam was completed in
1956 and flooded their valley
• The dam only provided electricity to the capital, skipping poor residents and the rural
towns
• “water refugees” – most did not receive any compensation from the government or the
companies involved when their lands and homes were flooded; most did not know it was
going to be built
• Haiti’s roots of their vulnerability
o government enthusiasm for big infrastructure projects
o creation of development agencies that pushed such projects
o rise of authoritarian governments that followed the U.S. military occupation and
preceded the Duvalier dictatorships as the immediate precursors of their
displacement
o Haiti’s history as a slave colony, lack of education and fair land practices in rural
Haiti
Acephie’s Joseph’s Story
• Daughter of a couple who had lost their home and land when the water rose
• Her beauty – she was tall – her vulnerability may have sealed her fate in 1984
• 19 years old and needed to make money for her family; she began to carry produce to a
local market; the soldiers liked to watch the parade of women on Friday mornings;
sometimes they taxed them, or flirted with them
• flirtation is seldom rejected; in rural Haiti, entrenched poverty made the soldiers – the
region’s only salaried men – more attractive
• her good looks caught the attention of a captain (who had a wife and children); he was
known to have more than 1 partner
o were sexual partners briefly
o she didn't know he would give her a bad illness; she knew she should stay away,
thought he was a way out
• the captain fell ill shortly after
• she was looking for a moun prensipal – “a main man”
• went to cooking school – where the poor girls get prepared to work as servants; being a
maid was growing into an industry in Haiti; Ascephie had no alternatives
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• at 22, worked at U.S. embassy women’s house; not paid well, later met a guy and planned
to marry
• later she got pregnant, the guy barely came to see her, the embassy woman was not happy
with a pregnant person; went back to Cange; soon diagnosed with AIDS
• daughter was infected with the virus too
• the captain’s wife and partners were infected with HIV, and their children; in addition,
her family felt pain from this disease; her dad committed suicide
• the water refugees and their descendants called for equity and redress; they became the
teachers of PIH
• working in Cange also taught PIH how to design interventions seeking to counter the
effects of structural violence: programs to diagnose and treat patients with TB and
without sufficient food
• the life experiences of Acephie and other Haitians living in poverty, in addition to
knowledge of Haiti’s history and political economy – showed the importance of
designing programs to meet the needs of patients facing both poverty and chronic illness
Tuberculosis in Haiti
• The Spanish gave them sugar cane, slavery, smallpox, measles, typhoid and TB when
they first came to Haiti
• 1944 – TB the most important cause of death among hospitalized patients
• the high prevalence of TB linked to poor sanitation and poverty
• PAHO – in 1965 said there was TB at 3,862 cases per 100,000 inhabitants
• By the 1990s, the high prevalence of TB was complicated by the advent of HIV
• 45% of all TB were reported to be infected with HIV
• drug resistance to TB is a problem, but the biggest problem is designing and
implementing programs that meet the needs of the afflicted; until that happens, a
diagnosis of TB will lead too rarely to a curative treatment
• in one town in Haiti, 75% of patients abandoned treatment in 6 months and 93% in 1 year
• important that the PIH/ZL program:
o takes into account the crippling poverty that plays a role in who does or does not
benefit from intervention
o avoid the “either-or” approach – acceptable to defer TB treatment while the “root
causes” of the disease by addressed through development projects
Building a TB-Control Program
• accompagnateur – community health worker; to implement the efforts of facility-based
clinicans
• Sector 1 – people living in small villages
• Sector 2 – more loosely demarcated villages
• Both sectors offered the same clinical services, but sector 2 was not served
accompagnateurs, nor did they benefit from activities sponsored by ZL, such as women’s
health initiatives, vaccination campaigns, water protection efforts, literacy groups
o Implemented by accompagnateurs - a powerful means to addressing malnutrition,
diarrheal disease, measles, neonatal tetanus, and malaria
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Document Summary
6 building an effective rural health delivery model in haiti and rwanda. Haiti: history: brutal labor system gave way to the largest slave revolt in history, first black republic in the world; born in 1804, the majority of the population, remains rural smallholder farmers, increasingly excluded. Cange: partners in health and its sister organization, zanmi lasante, were launched in the mid- It"s not the patients" beliefs that led to poor outcomes, but rather an ineffective and costly. To the patient delivery system that led to failure: relying on accompagnateurs became the standard of care for pih/zl tb programs. In 2001, the initiative helped lead to the harvard consensus statement on art for. Aids in poor countries : their small victories also reinforced advocacy efforts for universal access to. Aids treatment, culminating with the who"s 3 x 5 initiative. Pih in rwanda: inshuti mu buzima: pih began working in rwanda in 2005, they would work closely with the public sector.
