Previous
Replication of the activities described has not always been successful. Rural Haitian informants pointed out that teams often arrive late, in the heat of the day, and may abruptly cancel a session with little or no explanation. Furthermore, no shady area for seating the mothers was provided as might have been the case had the villagers participated in the planning of the sessions.
Haitian families today are more mobile than ever, and this effect is felt especially in the United States and Canada. Of 336,394 Haitians legally entering the United Sates between 1956 and 1972, about 230,000 were known to have remained. It was estimated that equally as many may have entered illegally.
High mobility may be blamed on the phenomenon of "overpopulation, extreme poverty, and one repressive regime after another" in Haiti. But other reasons underlie this instability. The system of small landholding involves owning land on dispersed plots; the sale or inheritance of land often requires migration (G Berggren et al., 1980) and demographic changes that affect household and family structure (G Berggren et al., 1980). What emerges is a stepwise movement from household to household, from village to village, and finally from villages to towns and onwards.
Comments on Strategy
The use of an itinerant technical support team to supplement the activities of village-based workers at regular (at least quarterly) intervals is necessary in rural Haiti in order to provide immunizations, growth-monitoring services, and other modalities (such as materials for a mini antenatal clinic). Rural Haitian mothers do not carry their babies on their backs or in a sling, and therefore the distance they are willing to travel for immunizations must be taken into account. Services must be within a one-hour walk of their homes for rural Haitian mothers to begin to come regularly to surveillance or immunization services (Alvarez et al., 1993). Rural community leaders are willing to participate and, in the case of the HAS under-fives clinic, have assessed themselves to help cover costs.
While the above activities began in a systematic way at HAS with the purpose, in part, of providing the basis for a prospective longitudinal study, it was realized that the systematic registration and follow-up of all family members in each nuclear family in every village in a defined census tract also brought the element of equity to the primary health care system. In Bangladesh, where the methodology is being replicated by Save the Children, health workers justified the approach as the "No Child Shall Be Left Out" system.
The HAS family registration system proved so valuable that by 1992 it covered the HAS district of 180,000 people in rural Haiti. Major changes evolved over the 25-year intervention period in order to improve primary health care, surveillance, and equity. These included the use of outlying dispensaries and the identification, recruitment, and training of community-level women volunteers known as animatrices, each of whom reaches 10 to 15 families, acts as a liaison to health services, and helps to organize village-based under-fives clinics.
Cultural Insights
Rural Haitian informants point out that communities lose faith with teams that often arrive late, in the heat of day, or with the news that a session is abruptly canceled or lacks supplies. Furthermore, villagers need to have participated in the planning of the project and in its appointed sessions. They will see, for example, that shaded areas and seats or mats for waiting mothers are available.
Conjugal union status was a confusing subject and one of special interest, since it was key to the understanding of household structure and child relocation in rural Haiti. At the time of family registration, interviewers found that up to one-third of women who had been in at least one conjugal union were without a male consort. RHVs who served as census takers consistently gathered more information than was asked for, and often information essential to the understanding of union formation and dissolution. The World Fertility Survey later piloted their questionnaire in the PISP project and developed a questionnaire that allowed for the history of unions to be correlated with the prolonged interpregnancy intervals that often occurred between unions.
The general instability of the Haitian population, in terms of both conjugal unions and high migration rates, was to some degree a reflection of the economic circumstances, as their reasons for in-migration betrayed. Nearly 20% of in-migrant males aged 15 to 44 gave "nonagricultural employment" as their reason for migrating, and another 18% gave simply "unemployed, unsettled" as a reason. Another 20% gave "to join a relative" as a reason, most often also because such a migration would improve their economic circumstances.
In these studies, one sees at once a reflection of the cultural factors described and, at the same time, adverse consequences, at least in nutritional terms, for relocating children. Child relocation can be seen as a strength carried over from the African cultural setting or as a detrimental consequence of highly unstable conjugal unions and family mobility in Haiti, where both phenomena occur under adverse economic conditions. In dealing with these families, the authors found that once displaced, a child was also apt to be displaced again, and that malnutrition often ensued (Rawson and Berggren, 1973). The PISP longitudinal studies found that up to 20% of children under two were separated from their biologic mothers, and that 13% died in the first six months thereafter. Therefore, as protective as "child sharing" might be in the African cultural setting, in this culture its effects are generally adverse for the child.
Rapid assessment procedures including the use of focus groups are beginning to add understanding to the situation of women who head single-parent families and whose common complaint is "My mister abandoned me." These insights are important for those who set targets for family planning: women outside of unions do not wish to give-up the "fertility card" they feel may be necessary to gain a new male consort. Evolution of the projects has included the adaptation of rapid assessment techniques from the behavioral sciences for development of education tools, monitoring, and evaluation.
Practical Implications for Health Programs
a. These studies imply the desirability of home-based health records for every age group, since rural Haitians are highly mobile and are unlikely to continue to attend the same health center for long. Haitian mothers in both studies proved they do not lose home-based personal health records if health providers are faithful in their insistence on their being presented and interpreted, and they will use them as educational tools.b. The information system that made the studies possible began in all cases with door-to-door registration of all families living in defined communities, with follow-up thereafter from RHVs (1:100 families) who acted as liaisons to the health services and reported all pregnancies, births, deaths, migrations, and nutrition status of children.
c. Resistance to family planning can be expected from women whose union status is in fluctuation. More educated Haitian women may feel that between unions it is in their own interest to continue the use of contraception, or to have contraceptives always available. However, until this philosophy or belief is shared by their less well-off sisters, up to one-third of women will be unlikely to use family planning because of instability of unions.
d. The adverse consequences of child relocation are not realized by Haitian families, who mean to provide better for their children by relocating them. Education about family building and the importance of bonding in child development could be included in the outreach programs of many institutions in Haiti. Nutrition education, for example, need not dwell exclusively on scientific facts about what a child needs to eat and how often. Haitian families care for their children and deserve a better chance to understand the value of family stability for both mothers and children.
e. Rawson's conclusions from his anthropological study of child relocation are relevant for health programs:
•Child relocation is an important underlying cause of malnutrition. If recognized early enough, the ensuing malnutrition is susceptible to simple preventive measures.•Child spacing and smaller family size would reduce the risk of relocating a child; hence family planning could contribute positively.
•In addition, the health staff should identify relocated children promptly and then institute action to protect them.
In conclusion, population-based community health programs have produced longitudinal data in Haiti to confirm that low-cost, simple interventions can lower mortality rates in children. A 25-year follow-up study at HAS proved that the rates were sustained in that setting, where primary health care and referral facilities remained constant.
This review was made possible through the Community Health Department of the Hospital Albert Schweitzer of Haiti and its supporting agency, the Grant Foundation of Pittsburgh, PA, and the Pew Charitable Trusts. The projects described were funded in part through grants from the Rockefeller Foundation, the Williams and Waterman Foundation, the Canadian International Development Research Center, Bread for the World of Germany, and the United Nations Fund for Population Activities (UNFPA) through the Division d'Hygiene Familiale of the Canadian Government.
Allman J. May J. 1979. "Fertility, mortality, migration and family planning in Haiti." Pop Stud 3:505 - 521.
Alvarez M, Berggren G. Gay M.1993. "Evaluation report on the CARE-Riches project in Haiti." Consultant Report to CARE (available through Susan Igras, CARE/Haiti). Port au Prince, Haiti: CARE.
Augustin A. 1993. Report to UNICEF on child health and mortality. UNICEF: Port au Prince, Haiti.
Beghin I, Fougere W. King K. 1970. L'Alimentation et la Nutrition en Haiti. Paris: Presses Universitaires de France.
Berggren G. Vaillant H. Gamier N. 1974. "Lippes loop insertion by midwives in healthy and chronically ill women in rural Haiti." Am J Public Health 64:719-722.
Berggren G. Berggren W. Ewbank D. 1980. "Haiti's Artibonite Valley migration and instability." Migration Today 8(1):3-23.
Berggren G. Alvarez M, Genece E, Amadee-Gedeon PM, Henry M.1984. The Nutrition Demonstration Foyer: A Model for Combating Malnutrition in Haiti. Hoviprep Monograph Series No 2, International Food and Nutrition Program of MIT. Cambridge, MA: MIT Press.
Berggren G. Hebert J. Waternaux C. 1985. "Comparison of Haitian children in a nutrition intervention program with children in the Haitian National Nutrition Survey. " Bull WHO 63:1141- 1150.
Berggren WL. 1971. "Evaluation of the effectiveness of nutrition rehabilitation and education centers." In: White PL, ed. Proceedings of the Western Hemisphere Congress on Nutrition III. Chicago: Department of Food and Nutrition, Division of Scientific Activities, American Medical Association Press.
Berggren W. Berggren G. Ewbank D. 1981. "Reduction of mortality in rural Haiti through a primary health care program." N Engl J Med 304:1324-1330.
Berggren W. Berggren G. Genece E, Henry M, et al. 1983. Enquête su la Nutrition et la Santé. Projet Intégré de Santé et de Population [PISP], Division d'Hygiene Familiale, Department de la Santé Publique et de la Population d'Haiti. Port au Prince: Les Ateliers de Fardin (Fardin Press).
CARE. 1993. Recommendations to CARE for nutrition intervention. Consultant Report of Expert Team. Port au Prince: CARE.
Casey A, Escher M, Krogstad D. 1971. Reports on tuberculosis to the Community Health Department of the Hôpital Albert Schweitzer (HAS). Follow-up on a survey for active tuberculosis in the HAS census tract of twenty-three villages near Deschapelles. (Carried out under the supervision of WL Berggren, Department of Tropical Public Health, Harvard School of Public Health.)
Cayemittes M and Chahnazarian A. 1989. Survie et Santé de l'Enfant en Haiti: Resultats de l'Enquête Morbidité, et Utilisations des Services. Port au Prince: Institut Haitien de l'Enfance, Editions de l'Enfance.
Clerisme C. 1979. Recherches sur la Medecine Traditionelle. Projet Intégré de Santé et de Population de Petit Goave, Division d'Hygiene Familiale, Department of Public Health and Population of the Government of Haiti. Port au Prince: Fardin Press.
Farmer P. 1992. Preliminary results from the primary health care project of the Episcopal Mission in Cange, Haiti. Cange, Haiti: PVS reports.
Farmer P. Robin S. Ramilus SL, Kim JY. 1991. "Tuberculosis, poverty, and compliance: lessons from rural Haiti." Semin Respir Inf 6:154-260.
Graitcher PL, Gedeon MA, DeBeausset I, Duckett EM. 1980. "Haiti Nutrition Status Survey 1978." Bull WHO 58:757-765.
Haiti Bureau of Nutrition. 1979. Haiti Nutrition Status Survey. Bureau of Nutrition, Department of Public Health and Population, Haiti, in cooperation with US Department of Health, Education, and Welfare, HEW, PHS/CDC and AID. Washington, DC: HEW,PHS/CDC/ AID.
Harvard Center for Population and Development Studies. 1993. "Sanctions in Haiti: crisis in humanitarian action." Program on Human Security Working Paper Series. Cambridge, MA: Harvard Center for
Population and Development Studies, Harvard School of Public Health 1993:5-7.
Institut Haitien de Statistiques. 1980. Demographic Report of the Haitian Institute of Statistics. Port au Prince: Haitian Institute of Statistics.
Jelliffe D, Jellife P.1961. "The nutritional status of Haitian children. " Acta Tropica 18:1-45.
King KW. 1964. "Development of all-plant mixtures using crops indigenous to Haiti: amino-acid composition and protein quality." Econ Botany 18:311-322.
King KW, Fougere W. Hilaire A, Webb RE, Berggren W. Berggren G. 1978. "Preventive and therapeutic benefits in relation to cost: performance over ten years of mothercraft centers in Haiti." Am J Clin Nutr 31:679-690.
Menager H. Tamari M. 1990. Consultant Report to Save the Children/ USA. Findings from review of ongoing census information in the Maissade Area census tract. Westport, CT: Save the Children.
Paisible P. Berggren G. 1984. Demographie et fécondité dans le Projet Intégré de Santé et de Population. Projet Intégré de Santé et de Population, Division d'Hygiene Familiale, Departement de la Santé Publique et de la Population. Port au Prince: Les Ateliers de Fardin (Fardin Press).
PISP (Projet Intégré de Santé et de Population).1982. Administration et organisation d'un programme communautaire de santé et de population en milieu rural. Division d'Hygiene Familiale, Departement de la Santé Publique et de la Population d'Haiti. Port au Prince: Les Ateliers de Fardin (Fardin Press).
Rawson I, Berggren G. 1973. "Family structure, child location and nutritional disease in rural Haiti." Environ Child Health 19:288-298.
Reinke W, Stanton BF, Roberts L, Newman J.1993. Rapid assessment for decision making: Efficient methods for data collection and analysis, WASH Field Report No. 391. Washington, DC: WASH Project.
Scrimshaw S. Hurtado E.1987. Rapid assessment procedures for primary health care. Latin America Studies Center, UCLA, Los Angeles, CA.
Taylor C. 1992. "Surveillance for equity in primary health care: policy implications from international experience." Int J Epidemiol 21:10431049.
Theodore H. 1992. Analyse de la mortalité maternelle. Port au Prince: Imprimerie Henri Deschamps.
UNICEF. 1990. State of the world's children. New York: UNICEF.
UNICEF. 1993. State of the world's children. New York: UNICEF.
USAID. 1992,1993. Humanitarian situation: Monitoring report updates. Port au Prince: United States Agency for International Development.
Williams S. Berggren G. Murthy N. 1975. "Conjugal unions in 425 rural Haitian women." J Marriage Family :1022-1027.
Word Vision. 1992. Report on baseline survey for child survival program, Ile de la Gonave, Hairi. Consultant report to Dr. Dyer. Port au Prince: World Vision
World Vision. 1993. Final evaluation of child survival project, Ile de la Gonave, Haiti. Consultant report to Dr. Dyer. Port au Prince: World Vision.
Ascoli W. Guzman MA, Scrimshaw NS, Gordon JE.1970. "Nutrition and infection in Guatemalan villages 1959-1964." Arch Environ Health 15:439-445.
Berggren G. Favin M. 1992. Social mobilization for the elimination of tetanus of the newborn; Working Paper of the Mothercare Project. Boston, MA: John Snow, Inc.
Berggren G. Murthy N. Williams S. 1974. "Rural Haitian women: an analysis of fertility rates." Social Biol 21 :368-378.
Berggren G. Berggren W. Verly A, Gamier N. Peterson W. 1983. "Traditional midwives, tetanus immunization, and infant mortality in rural Haiti." Trop Doctor 13:79-87.
Berggren W. 1974. "Administration and evaluation of rural health services; I. A tetanus control program in Haiti." Am J Trop Med Hyg 23:936-949.
Berggren W. Berggren G. 1971. "The changing incidence of fatal tetanus of the newborn." Am J Trop Med Hyg 20:491-494.
Bordes A. 1982. "The impact of breastfeeding and pregnancy status on household contraceptive distribution in rural Haiti." Am J Public Health 72:835-838.
Finlay S.1990. Report on neonatal tetanus in Haiti. Special report to the Immunization Office of the Pan American Health Organization. Washington, DC: PAHO.
Fougere W. King K. 1975. "Capitulation as key ingredient to eradication of severe malnutrition in children." J Environ Child Health 21 :240248.
Gomez F. Ramos-Galvan R. Frank S. et al. 1956. Mortality in second and third degree malnutrition. J Trop Pediatr 2:77-83.
Herskovitz MJ. Life in a Haitian valley. 1937. New York: Alfred E. Knopf.
King K. "Food patterns in dietary surveys in rural Haiti. " 1968. J Am Diet Assoc 53:114-118.
King KW, Fougere W. Foucauld J. Dominique G. Beghin I. 1966. "Response of preschool children to high intakes of Haitian cereal-bean mixtures." Arch Latinoam Nutr 16:54-64.
Management Sciences for Health [MSH].1992. Using maps to improve services in family planning; Family Planning Manager. Newton, MA: MSH, 1(5).
Menager H. Berggren G. Preliminary Report to the Hôpital Albert Schweitzer Alumnae Reunion, July 1992 (unpublished).
Morley D, Woodland M. 1979. See how they grow. New York: Oxford University Press.
National Institute of Nutrition, Bogota. 1969. A practical guide to combating malnutrition in the preschool child: Report of a Working Conference on Nutrition Rehabilitation and Mothercraft Centers. New York: Appleton-Century Croft.
Sebrell WH, et al. 1959. "Appraisal of nutrition in Haiti." Am J Clin Nutr 7: 1-48.
Sirinit K, Soliman A, Van Loo A. 1965. "Nutritional value of Haitian cereal-legume blends. " J Nutr 86:415-423.
1 Formerly with the Albert Schweitzer Hospital in Deschapelles, Haiti and the Harvard School of Public Health in Boston, MA, USA.
2 Albert Schweitzer Hospital, Deschapelles, Haiti.
3 Formerly with the Integrated Project of Health and Population, Division of Family Hygiene in Petit Goave, Haiti.