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Background on Haiti
Materials and methods
Berggren,1 Henri Menager,2 Eddy Genece,3
and Calixte Clerisme3
Nongovernmental organizations (NGOs) play a key role in the development of community-oriented primary health care (COPHC), and now provide more than half of all primary health care services in Haiti (Augustin, 1993). One of these, the Hôpital Albert Schweitzer (HAS) Community Health Department, has a population-based, community-oriented health project in rural Haiti which has produced relevant country-specific research since 1968. It has contributed to the fund of knowledge about COHPC, community epidemiology, and research. In an article entitled "Surveillance for equity in primary health care: policy implications from international experience," Taylor (1992) cites the HAS study for its documentation of reduction of early childhood mortality to one-quarter of its earlier levels in less than five years, due first of all to a reduction in tetanus of the newborn, and also to a village-level health and nutrition surveillance program which impacted on malnutrition, diarrhea, and tuberculosis.
Although the project cost less than $ 1.60 per capita per year in the early 1970s (W Berggren et al., 1981; Taylor, 1992), it was thought not to be replicable under the conditions in most Haitian government rural health services. This idea was disproven in a special study of the project by the Ministry of Health and Population of Haiti, the Division d'Hygiene Familiale, the Projet Intégré de Santé et de Population (PISP) under Dr. Ary Bordes (Clerisme, 1979; PISP, 1982; Paisible and Berggren, 1984).
Recent findings from a follow-up study of the original census tract and two others within the HAS catchment area, published here for the first time, reveal that the reduction has been maintained despite worsening economic conditions in Haiti. This chapter reviews key results from the HAS study as well as some similar findings from three other prospective longitudinal studies in rural Haiti, each benefiting from lessons learned in the HAS study. They include the PISP project (see above), the Save the Children/USA project in Maissade (SCF/Maissade), and the Projet Veye Santé (PVS) in the Cange area, supported by Zanmi Lasante, Port-au-Prince, Haiti, and Partners in Health, Cambridge, MA, USA.
In all projects, defined communities were mapped, followed by community participation in house numbering and family registration. Rosters of children under five and of women in the reproductive age group derived from the family registers enabled workers to keep track of children and mothers needing immunizations, family planning, vitamin A distribution, and other services, such as education in the prevention of sexually transmitted diseases, including AIDS. Home-based, hand-held records such as immunization cards and the "Road-to-Health Weight-Age" chart for children under five were distributed, carried, and rarely lost by Haitian mothers trained in their use and interpretation.
Elements of the first project, ongoing since 1967 in villages served by HAS near Deschapelles, now reach the entire catchment area of 180,000 people. Although longitudinal reporting was gradually dropped after the first five years of the project at HAS, a 25-year follow-up study carried out in 1992 showed that the reduction in childhood mortality rates in the original census tract had held despite worsening economic conditions. The 1992 study at HAS, using World Fertility Survey techniques, studied two other census tracts for comparison purposes: one in the mountains around Bastien, and one known as Plassac, separated from HAS by an often impassable river. In the latter, local volunteer women's health workers (animatrices) serve as liaisons to villages. Significant trends in the reduction of childhood mortality rates were documented in all three census tracts, with rates in villages nearest HAS being lowest. Little reduction in fertility rates was noted, despite ready access to family planning services.
In the initial studies, itinerant Centres de Rehabilitation et Education Nutritionelle (CERNS) were shown not only to prevent deaths but to be cost-effective in rehabilitating malnourished children and reducing hospital admissions for kwashiorkor and marasmus (WL Berggren, 1971). The Haitian government's PISP team modified the CERNS to reach mothers with a two-week, village-level workshop (Foyer de Demonstration en Nutrition) with lower cost and good results in training mothers so that they not only rehabilitated their own malnourished children with locally available foods but prevented malnutrition and death in younger siblings (G Berggren et al., 1984).
Such methods and lessons learned from the HAS project and the Haitian government's PISP project have now been applied in at least two other projects, reaching defined populations of more than 40,000 each, and in a current project at HAS. The SCF and PVC projects are now performing longitudinal "small area studies" as they work out least-cost methods of primary health care delivery and document impact. Their defined populations were initially registered, often as part of a baseline survey, and then followed with vital event reporting as community health activities were instituted. The PISP project, however, was the only one to study a "comparison area" at midpoint as well as carrying on an annual census to double-check on vital events. A map with census data is shown in Figure 1.
The prospective longitudinal community-based studies described in this chapter serves to:
a. show how community-oriented primary health care (COPHC), when carried out in defined populations served by locally recruited, trained, and supervised resident home health visitors, has a measurable impact on poor Haitian communities;
b. review the determinants and consequences of high fertility, mortality, and morbidity rates in rural Haiti as revealed by these studies;
c. present lessons learned from these studies in developing practical methods to combat infectious disease and malnutrition in rural Haiti.
Haiti, the western half of the island of Hispaniola, covers 27,700 km2, much of it hilly and heavily forested when first discovered. Slaves were brought from Africa as early as 1510; slave ships continued to arrive over the next two centuries, bringing agricultural labor necessary for French colonial plantations of rice, cotton, tobacco, and sugarcane. The rich forest was cut for lumber to build towns as well as for export; mahogany was exported to France by the ton (Rawson and Berggren, 1973).
A brave and independent people took over their own country from the French in 1804, and became the first Black republic. The turbulent first years were characterized by efforts at establishing some kind of economy based on various types of land grants. In the north, these were large, plantation-size holdings. In the rest of the country, the grants were made outright and varied in size according to the status of the recipient (Rawson and Berggren, 1973). Today peasant farmers have many small landholdings, growing ever smaller as they are divided among daughters and sons.
Since independence, Haiti has been besieged with a series of governments that were often dictatorships with little interest in bettering conditions for the common people, and until the election of President Aristide, little democratic process emerged. As a result of this and of degradation of the environment, Haiti's population of more than six million people suffer the worst or nearly the worst health and environmental conditions in the Western Hemisphere (UNICEF, 1993). Due to deforestation, Haiti's once rich soil washes into the sea, choking with silt the coral reefs that were home to an abundance of fish. Less than one-third of the land is arable, and it is now divided into very small farms occupied by peasants who own their land but are 70% illiterate.
Name and Location of Study Area
HAS census tract (original)
HAS Plassac and Bastien census
PISP (Petit Goave area)
Comparison cluster sample area
SCF (Save the Children/Maissade)
PVS (Projet Veye Santé/Cange)
The Haitian sense of community and of family stability may still be suffering from the breakdown of institutional structures imposed by slavery. Unstable conjugal unions, child-sharing practices, serial polygamy, and a propensity for women over 35 years of age to become single-parent heads of households characterize rural Haitian families (Paisible and Berggren, 1984; Rawson and Berggren, 1973). One-fifth to one-third of women over 39 years of age can expect to live in a separated or divorced state, according to recent studies (Cayemittes and Chahnazarian, 1989).
Haiti's culture is considered neo-African by anthropologists. The "whys" and "hows" of family building hark back to the whole history of the slave trade, which broke up thousands of families initially and then continued the transfer of slaves without regard for conjugal unions.
Today Haiti does not produce enough rice or other cereals to meet its own needs. Cocoa, sugar, and coffee production have been interrupted and damaged by a trade embargo imposed by the international community in an attempt to restore the democratic process from 1991 to 1993. Planting hillside crops of corn, millet, cassava, beans, and peanuts enables rural farmers to survive on small parcels of land. In some areas, such as the Artibonite Valley, irrigated crops include rice and sugarcane. Recent breakdowns in water management have put even these crops at risk.
Health indicators for Haiti reveal a maternal mortality ratio of 345/ 100,000 live births (Theodore, 1992) and an infant mortality rate at or near 100/1,000 live births/year (Cayemittes and Chahnazarian, 1989). About 159 children/1,000 (16%) can expect to die before their fifth birthday (Cayemittes and Chahnazarian, 1989). Diarrhea is blamed for nearly one-fourth of the deaths, followed by respiratory illness; however, these are usually superimposed on malnutrition which is the underlying cause of death (Cayemittes and Chahnazarian, 1989).
Malnutrition has long been a serious problem. Jelliffe and Jelliffe (1961) found that 7% of Haitian children under five suffered nutritional edema. A national nutrition survey found half that rate in 1978 (Graitcher et al., 1980). Nevertheless, nearly one-third of children continued to suffer moderate to severe malnutrition by Waterlow standards (Graitcher et al., 1980). The average daily calorie intake according to various surveys in the 1970s was about 1,500 kcal (6,300 kJ)(G Berggren et al., 1985).
Recent studies reveal a possible worsening of the nutrition situation. In the Northwest, a famine-prone area, in communities where food was being distributed, 5% to 10% of children had arm circumference measurements consistent with severe malnutrition (CARE, 1993). On Ile la Gonave,6% of children were acutely malnourished and 24% were chronically malnourished by Waterlow classification (World Vision, 1992). HAS experience in the Artibonite Valley showed that around 20% of children suffer second-degree malnutrition, and 2% to 3% of children continue to suffer Gomez third-degree malnutrition, despite an intervention program. A USAID-funded monitoring system continues to report that third-degree malnutrition affects 3% to 4% of children in most parts of Haiti (USAID 1992, 1993).
private voluntary organizations continue to deliver much of the
primary health care services in Haiti, often in concert with
poorly equipped government institutions nearby. The Haitian
Government's Ministry of Health (Ministère de Santé et de
Population) works on a slim budget, paying and equipping its
staff minimally to run its hospitals and dispensaries. WHO
advisors estimated that in 1992 it spent 93% of its budget on
salaries in the face of the international sanctions. Although
malnutrition is a number one problem, no national nutrition
All projects found that rural Haitian families respond well to the use of resident home-health visitors and their volunteer assistants, who are often women. The latter have helped to report vital events and assisted their neighbors to go to neighborhood posts-de-rassemblement (assembly points or rally posts) for immunization, growth monitoring/counseling, and family planning. Outreach teams from nearby health centers provide technical support to back up village workers who help carry out a census and/or enroll families in the community health program. After door-to-door registration of families, the resident home visitors derived rosters of children under five and of women in the reproductive age group for follow-up. Vital event reporting permitted the use of indicators such as birth rates, age-specific fertility rates, and age-specific, cause-specific death rates, as well as certain morbidity indicators.
the projects reviewed here are underlying concepts; the most
important is that the family is the key primary health care
provider or enabler, and health workers are their trainers.
Other common concepts were:
a. Equitable distribution of preventive health services (through community registration of families or households; no one is left out);
b. Community involvement with services offered through locally recruited and trained resident home visitors (RHVs), or family workers;
c. The need for ongoing health and nutrition surveillance activities and preventive services at the community level (for example, community-based distribution of contraceptives in the PISP project; periodic deworming and vitamin A distribution in others);
d. Use of vital event reporting and reporting on nutritional status of children as a part of an emerging "management information system" (for example, data such as birth rates and age-specific, cause-specific death rates were used for community diagnosis and for decision making);
e. The need for continuing community participation in the primary health care system, with feedback to the community from the information system;
f. Use of an itinerant technical support team to assist community workers in the delivery of key preventive services, such as immunization, and growth monitoring as close to homes of villagers as possible;
g. The need for education of families and traditional birth attendants in appropriate early referral for illness or complications of childbirth.
Both HAS and the PVS/Cange programs have the advantage of an excellent curative institution nearby. The PISP project relied on an under equipped government hospital with erratic services at the time (for example, lack of 24-hour-a-day coverage for emergency illnesses or conditions). Reliable services for early referral of ill persons emerged as a key concept for the more successful of the projects.
Paid full-time or part-time community health workers or RHVs, often called Agents de Santé in Haiti, acted as family educators and as reporters, assisted by local volunteer community health assistants and/or women's groups or their supervisors. These workers were recruited, trained, and supervised locally by technical support teams of health professionals at nearby institutions.
Through their home visits and work with community leaders, the RHVs were able to implement community-based health rallies where preventive activities could occur. Attendance at the monthly or bimonthly community-based sessions was enhanced by offering services near the homes of mothers, who rarely will walk more than one hour for preventive services (Alvarez et al., 1993). Other enhancements included the addition of simple first aid or beginning curative care for ill children, the provision of free worm medicine, and the availability of vitamin A supplements.
In addition to vital event reporting and nutrition surveillance, RHVs focused on training families in the following activities:
a. Use of oral rehydration therapy (ORT);
b. Seeing that children are breast-fed, immunized, and attending nutrition monitoring/counseling (including vitamin A supplementation in more recent programs);
c. Finding contraceptive services;
d. Finding primary health care facilities in cases of respiratory infections or febrile illness.
Mothers under surveillance were asked to participate in growth monitoring/counseling; to prolong breast-feeding; to use trained birth attendants; to take advantage of maternal health services such as family planning, antenatal care, and postnatal care; to use project-trained traditional birth attendants; and to adopt behaviors to prevent AIDS.
The overall strategy differs little among programs. The following steps, or modifications of them, were considered necessary by all of them:
1. Map out defined communities to be served, with community participation in planning for house numbering and door-to-door registration of families so that no family is left out (a concern for equity);
2. Identify, recruit, and train community health workers, ideally RHVs and local assistant workers (including volunteers) who will participate in activities such as teaching mothers and inviting mothers and children to assembly points or "rally posts" for preventive services and some curative services;
3. Implement an information system with appropriate indicators so that impact evaluation is possible:
a. Derive rosters from the family register or "census" instruments, for example, community-based rosters of names of children under five or under three years old (one roster for every 20-30 families) so that health workers (one worker for every 30-100 families) can record serially the weight/age and immunization status for each child he or she follows through assembly post activities;
b. Create and test or adopt report forms (for example, government immunization report forms, and pregnancy, birth, and death report forms for the local program);
c. Create, test, or adapt home-based, hand-held record forms to be carried by mothers (such as vaccination cards), Road-to-Health weight/age growth monitoring graphs, and maternal health records;
d. Train health workers in the use of these appropriate instruments;
e. Train supervisors in the use and creation of instruments for aggregation of data for feedback to communities and for reporting onward those data needed by program or project managers.
4. Train health workers at all levels to help set up "stations" for assembly posts at the community level (a station for immunizations and vitamin A distribution, a station for weighing children, a separate station for counseling the mother with participatory interpretation of the Road-to-Health weight/age graph, one for family planning counseling, etc.);
5. Train itinerant technical support teams to arrive monthly, bimonthly, or quarterly at the village level to carry out primary health care and nutrition monitoring activities according to a respected appointed schedule with an early-in-the-day arrival (rural Haitians arise at dawn or before, and prefer community-based activities very early or late in the day);
6. Inform community leaders and mothers of the purpose of the program and the date, time, and place of assembly points, often by a personal home visit on the eve of the activity;
7. Plan for absentee follow-up, sometimes during the activity or immediately thereafter (volunteers often did this);
8. Implement immediate vital event reporting in at least one defined project area to provide impact indicators. The absence of a supervised civil registration system in Haiti and the need to report vital events on a carefully defined local population necessitated this activity.
To explore whether good results could be expected if this kind of community health approach were to be undertaken by a government institution, the Haitian Ministry of Health Division of Family Hygiene in the PISP project, replicated and improved child survival and fertility control activities in defined communities near Petit Goave in 1974- 1978. Assisted by the Department of Population Sciences of the Harvard School of Public Health and the Haitian Institute of Statistics, prospective longitudinal reporting of pregnancies, births, and deaths was carried out in three "census tracts"; a nonintervened population was studied for comparison purposes.
In the PISP and HAS projects, all data on migrations were coded and computerized for further analysis and interpretation. Types of data available included a record of demographic variables and reasons for migration for all persons classified as immigrants, emigrants, or transfers within the census tract.
Rupture of the nuclear family during a move was a special concern to the investigators because of health and nutrition consequences. In the first HAS study all migrants and transfers were classified as "moving alone" or moving as a part of a family group. Reasons for migration as well as new and old addresses were also noted. The PISP study also noted whether any conjugal union had dissolved and whether any children under five had been separated from their biologic mothers as a result of the move.
Nutrition Monitoring and intervention
Rural Haitians tend to appear thin, reflecting their scant diets of rice, corn, cassava, or millet with a few beans, served once or twice daily. Most families can afford animal protein once a week at best; some have meat only once a month. The average daily calorie intake has been estimated as between 1,200 and 1,700 calories per day, with carbohydrates forming 72% of the daily intake (Haiti Bureau of Nutrition, 1979). Children suffer most, especially toddlers who cannot be expected to consume their daily calorie requirement at one sitting. Once weaned from the breast, however uneducated mothers will expect a child to do so (Beghin et al., 1970).
Because Haitian children under five have been and remain the most malnourished in the Western Hemisphere (UNICEF, 1990), special nutrition activities characterize these projects. During the 1970s and into the 1980s, rural nutrition surveys revealed that 3% to 6% of preschool children suffered Gomez third-degree malnutrition, that is, with weight/ age measurements less than 60% of the international standard median (Haiti Bureau of Nutrition, 1979). By 1992, data for sentinel surveillance areas set up by USAID still showed that 3% of Haitian children fell into the category of third-degree malnutrition (USAID, 1992, 1993).
Growth monitoring and reporting on nutrition status was a part of the nutrition surveillance system for all children in the HAS program and the PISP project. At HAS this included weight/height/age measurements monthly on more than 80% of census tract children. The Road-to-Health weight/age growth record was used to educate mothers in all projects at monthly, bimonthly, or (in the case of the PISP project) quarterly assembly posts, where immunizations, family planning, and health education were carried out.
Growth monitoring and nutrition surveillance and intervention activities were based on the following premises:
a. Rural Haitian mothers, although illiterate, can and will retain and interpret home-based growth charts on their children;
b. Nutrition demonstration-education involving the mother in food preparation and in feeding and rehabilitating her child is superior to counseling alone;
c. Continuing surveillance activities with periodic deworming and vitamin A distribution are appreciated by rural families, who will continue to participate as long as there is an outreach program that provides simple services within easy walking distance of their homes.
In 1968 the HAS community health program adopted a plan for nutrition intervention based on the experience of the Haitian Bureau of Nutrition, a part of the Ministry of Health of Haiti at the time. This was the use of village-level "centers" (temporarily rented homes) where a trained nutrition aide would teach mothers to rehabilitate their own malnourished tots using locally available, inexpensive foods. These nutrition rehabilitation and education centers or "mothercraft centers" lasted three months for each "promotion" of about 20 to 30 children and their mothers from a nearby neighborhood. The women nutrition aides, known as monitrices, moved with their center equipment in an itinerant manner across the HAS district, targeting those communities where the data from the growth monitoring indicated an acute need. Local farmers and their wives cooperated in making a home available for the demonstration and in observing the changes in the malnourished children. For the first time, mothers were shown the recuperation of children from kwashiorkor and marasmus by the use of inexpensive foods rather than treatment by medications received in hospital or clinic settings. Teaching emphasized the use of an inexpensive, locally available mixture known as akamil (one-third beans and two-thirds corn), which had an excellent amino acid ratio (King, 1964).
For HAS, this was a contrast to the traditional approach in which children were hospitalized, tube fed, and rehabilitated with imported products in a setting where cross-infection rates were high. Using the mothercraft centers in an itinerant manner across the HAS catchment area resulted in a significant decrease in the number of children requiring hospitalization for severe marasmus or kwashiorkor and was cost-effective (King et al. 1978). The PISP project in the Petit Goave area developed a less expensive modification of the mothercraft centers known as Foyers de Demonstration en Nutrition or nutrition demonstration centers, introduced in the context of the nutrition monitoring program, in which each mother was trained to follow the growth of her child on a home-based weight/age graph. The foyers lasted only two weeks in a village and took place in the borrowed kitchen or foyer of a volunteer mother who was a participant in the training exercise, whether or not her own child was malnourished. In this modification, the malnourished child was not completely rehabilitated but only began the process. The monitrice who conducted the training sessions met with villagers before, during, and after the demonstration to encourage completion of the rehabilitation process for each child in question.
The adverse nutritional consequences to children in unstable family situations were documented. Fostering of nonbiologic children is not uncommon in rural Haiti, especially in the face of dissolving conjugal unions. Children who were moved from one family to another in child-sharing practices typical of rural Haiti were followed prospectively to detect changes in nutritional status and survival.
Family Planning and Community-Based Distribution of Contraceptives
Although HAS was one of the first institutions in Haiti to introduce family planning, the program remained hospital- or dispensary-based until the recent AIDS epidemic (G Berggren et al, 1974). By contrast, door-to-door community-based distribution of contraceptives was an active part of the PISP project in the Petit Goave area as a part of its activities under Haiti's Division de Hygiene Familiale. The success of this approach was a harbinger of the community-based distribution projects introduced more widely in Haiti and elsewhere. The door-to-door activities of local volunteers (collaborateurs volontaires) who were part of the surveillance system enabled contraceptives to be made available at the community level. Over a three-year period, a crude birth rate of over 40/1 ,000/year came down to 37/1,000 with a concomitant high acceptance rate of condoms and pills. Many women also expressed their interest in the possibility of an injectable contraceptive (Paisible and Berggren, 1984).
The SCF/Maissade project, serving a very conservative rural population, has seen less success with community-based distribution activities but has found an apparently increasing interest and use of progestational implants (Norplant).
Tuberculosis and AIDS
Longitudinal death reporting revealed that tuberculosis was among the 10 leading causes of death in the HAS census tract in 1968; HAS studies in the Artibonite Valley in 1969 included a tuberculosis survey of the total population living in 23 villages near Deschapelles (see Results). Community-based activities included home visits, distribution of medication, and follow-up for compliance. A study carried out by PVS showed 2.4% active tuberculosis in the Cange census tract, including pediatric cases (Farmer et al., 1991). The PVS project included free tuberculosis drugs with or without financial aid.
Funding did not permit such a study by the PISP personnel in the Petit Goave area. However, tuberculosis emerged as a major cause of death in adults and therefore became a concern. All deaths were reported by cause using verbal autopsy methods. Those thought to be caused by tuberculosis were investigated by physicians who had access to the records of a tuberculosis treatment project in the area, funded in part by the International Child Care Foundation and Grace Children's Hospital for tuberculosis in Haiti.
Evolution of the Information System
All vital events were reported by RHVs, who discovered the vital event through home visits, "roll calls" of children under five or mothers at rally posts, or annual census updates. In the HAS studies, all deaths were investigated by physicians or their trained assistants; often an accompanying clinic or hospital record revealed the most likely cause of death. If not, physicians carried out informal verbal autopsies. At HAS they examined the cadaver, and in some cases convinced families to bring the body to the hospital morgue for autopsy in order better to determine the cause of death. Births were recorded by the RHVs, who contacted trained traditional birth attendants in each neighborhood.
mobility of rural Haitian families posed a special problem, not
only from the point of view of documenting vital rates, but also
for follow-up purposes. Haitian conjugal unions are very unstable
(Williams et al., 1975; Allman and May, 1979; ); their
dissolution is often followed by in- or out-migration from a
given census tract. The HAS definition of a resident was a person
who resided at least six continuous months in the census tract,
with intent to stay. The PISP project required that a resident be
present four months or more with intent to stay before their
vital event could be counted. Thus, vital events of visitors and
transients were eliminated from the final analyses.
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