Prayer and Preparation: How One Haiti Hospital is Confronting COVID-19

  • Posted on: 20 May 2020
  • By: Bryan Schaaf

May 18, 2020


Miami Herald

It was the biggest single-day increase since an ill-prepared Haiti first confirmed that the novel coronavirus had arrived at its shores. After days of single digits and spikes still in the teens, the number of confirmed infections in just one day had peaked to 39. Reading the latest update from the ministry of health on Thursday, Marc Jumlisse, a nurse at the University Hospital of Mirebalais, the first medical facility to open its doors to infected patients, had only one reaction. “I said ‘Let’s pray.’ ”

Jumlisse, who worked 12 years as a licensed practical nurse and registered nurse in the United States before moving back to Haiti in 2010, and the medical staff at Mirebalais have been dreading a tide in the deadly infections that they know is coming, and that the Pan American Health Organization warns could overwhelm an already weak health system. In just one week, the number of confirmed infections of COVID-19, the disease caused by the flu-like virus, had more than doubled in Haiti. They increased from 123 laboratory-confirmed cases on March 8 to 310 as of Friday. By Saturday, the number had jumped by an additional 48 cases and by Sunday, the number of confirmed infections stood at 456. Of that total, 20 people have died — four of them at Mirebalais.

While the spike in positive cases has yet to translate into a deluge of sick people at Mirebalais’s wrought iron gates, things are starting to get critical. Several directors of private hospitals earlier this week reported an increase in patients showing a range of severe symptoms that are the markings of the virus: respiratory problems, coughing, an acute fever. The government’s water agency reported the death of a driver from the coronavirus, and confirmed that several employees had been tested and were in self-isolation.

The director of the country’s prison system, while pushing back rumors that the virus had hit his overcrowded prison population, acknowledged that there was a rapidly spreading fever inside the National Penitentiary. On Thursday, residents in the coastal town of Arcahaie, 30 miles north of the capital, protested after hearing that 75 inmates at the prison in the middle of town had been moved to make room for eventual COVID-19 prisoners. And on Friday, the medical director of Port-au-Prince’s St. Luke Hospital, a private nonprofit that only recently began receiving COVID-19 patients, acknowledged that 11 patients suspected of having the disease had died since Sunday, within three to four hours of arriving at the facility. Dr. Marc Edison Augustin also said with infected patients desperately in need of life-saving oxygen, the hospital was running low on stock.

Marc Jumlisse, a nurse at the University Hospital of Mirebalais, the first medical facility in Haiti to open its doors to infected COVID-19 patients. Courtesy of Partners in Health The staff at Mirebalais, which is two hours from Port-au-Prince through the mountains of central Haiti, say they are also seeing an increase in the numbeof suspected COVID-19 patients who are critical, and know it’s just a matter of days before they, too, face tougher decisions.“‘What’s going through our heads is, ‘Get it ready,’ Jumlisse said. “How many beds do we have, how many can we get prepared? How many staff... how many people can we train now?”

With patients continuing to come for regular medical care, resources are being stretched thin. With a background in emergency response and public health, Jumlisse, wonders if she’s taking her best nurses away from other critical patients in the intensive care unit to put them in the COVID-19 treatment center, where an initial fear from healthcare workers to be assigned there has now turned into a raise of hands.

Loune Viaud, the executive director of Zanmi Lasante, the Haitian non-governmental organization that operates the hospital along with its U.S. partner, Boston-based Partners In Health, also worries. Hundreds continue to show up daily, traveling six hours or more on public buses and on the back of motorcycles to sleep in the hospital’s parking lot in order to secure a place in line at first light to see a doctor. “Every night when I go to sleep, I am thinking I am going to wake up and hear that the cases have spiked and they are going to send us more patients,” said Viaud, who is also running COVID-19 sites in St. Marc, Hinche and Belladère and has a team doing rapid testing at the Belladère crossing at the Haiti-Dominican Republic border.

According to Dominican immigration officials, 25,000 Haitians have returned to Haiti since the start of the pandemic, deepening fears of rapid community transmission given the high number of infections in the Dominican Republic, where the health ministry reported 12,314 cases on Sunday and 428 coronavirus-related deaths. Haitians are crossing despite the official closure of the border. Last week alone, 1,321 Haitians crossed the official Belladère border in Haiti’s central plateau, according to the International Organization for Migration. There are at least 59 other crossings, all unofficial and unmonitored, in the same region. ”I keep thinking, ‘What I am going to do when the cases start to increase, and for how long can we hold on?’ ” Viaud said.

A non-profit solar-powered teaching hospital, the University Hospital of Mirebalais is one of five officially designated COVID-19 hospitals in Haiti, where medical experts estimate they will need at least 9,000 hospital beds to combat the infection when it peaks. Combined, the hospitals have less than 300 beds devoted to individuals infected with COVID-19. Envisioned before Haiti’s devastating 2010 earthquake, the hospital’s $21 million construction was fast-tracked after the quake left more than 300,000 dead and the main government hospital was destroyed. Today, it is not just the country’s biggest operating hospital with its 300 beds but perhaps the best equipped to confront the global pandemic, even with just 17 beds dedicated to COVID-19 patients.

Unlike other health care facilities, which depend on an oxygen dispensing site in a gang-controlled area of Port-au-Prince, Mirebalais’ ventilation system produces its own oxygen and uses cylinders as back ups if needed. One COVID-19 patient could use a minimum of two to three cylinders of oxygen a day. The COVID-19 treatment unit at the University Hospital of Mirebalais in central Haiti before it received the country’s first two cases in mid-March. Courtesy of Zanmi Lasante Between the time the hospital received the health ministry’s Feb. 7 request asking if it could help care for COVID-19 patients, and when it received the call on March 19 saying Haiti had two confirmed cases and they were en route, staff had just six weeks to transform the hospital’s grounds.

Going into overdrive, they immediately started making preparations, doing so while managing threats from the neighboring community that they will burn the hospital if it were to open it doors to COVID patients. “We’ve tried to manage it,” said Viaud, who was forced to beef up police presence around the premises and called on local leaders for help. “That isn’t to say that the threat has gone away. But we’ve been trying to be more open and educate people as well.” With its own entrance, the COVID-19 response compound is located to the left of the main hospital, a 200,000 square-foot facility. Off limits to non-authorized personnel, the specialized compound includes a converted rehabilitation unit that is used for staff who test positive. The one-time Mother’s Waiting Home, where new and future moms were once housed while being monitored, was transformed for family members and others who have been exposed to the deadly virus and are in need of monitoring.

The actual COVID-19 treatment center was originally designed for patients with cholera and acute diarrhea, a leading cause of death for children under 5 in Haiti. It includes an intensive care unit for those who are critically ill. To gain access, staff must first suit up in hazmat personal protective wear covering every inch of their bodies. Dr. Benoucheka Pierre, who heads the unit, said there are five doctors, each with a different specialty, assigned to the COVID-19 patients. There are also seven nurses, four nursing assistants and housekeeping staff. There is a triage team that includes another set of doctors and nurses assigned to doing screenings of suspected cases. Within the unit, patients are further segregated. Those with underlying health issues like tuberculosis, for instance, are kept apart in another area that is separated by a glass partition. As soon as patients arrive, she said, they are immediately evaluated. Tests and X-rays are performed, and oxygen is given. Medication is also provided, she said, “to treat the COVID and whatever illnesses that accompany it.” All of it is free of charge.

Before beginning their shift, health workers first pass through the cafeteria where they eat, use the bathroom and prepare for a 12-hour shift that could go without a break in order to preserve the two personal protective equipment each is assigned per shift. On average, the unit is going through about 100 units of PPEs per week, and that’s only because the night shift staff works the entire 12 hours without ever exiting the unit. “We’re trying to conserve it because we don’t know what’s coming at us,” said Viaud. Before St. Luke’s Hospital opened in Port-au-Prince and took some of the pressure off, Mirebalais was it, receiving referrals from the ministry of health. One day last month, when cases were still moderate and small, staff counted 16 patients in 17 of the available beds. There was one suspected case in isolation, and five more were on their way.

The treatment protocol so far, Pierre said, has focused more on oxygen therapy rather than ventilator use. Pierre and the other doctors caring for COVID-19 patients benefit not just from their own experience of working at a teaching hospital, but that of a slew of physicians and global health experts outside of Haiti. These include Harvard’s Brigham and Women’s Hospital, the second largest teaching hospital of Harvard Medical School in Boston, and it’s Department of Global Health and Social Medicine. They also rely on expertise at Massachusetts General Hospital and of course Paul Farmer, the world renown medical anthropologist and infectious disease expert who is also the founder of Partners In Health.

Farmer and Viaud have been on the front lines of every major epidemic that has hit Haiti in the last three decades: HIV/AIDS, tuberculosis, cholera, Chikungunya and Zika. “Cholera, Zika — these were fast-moving regional epidemics when they hit Haiti. AIDS was a slow-moving global pandemic,” Farmer said. “COVID-19 is a fast moving global epidemic hitting everywhere at once.” Farmer is on the phone almost daily, the staff say, checking in on patients and discussing treatment protocol. “It’s the same drill,” he said about the approach to COVID-19 compared to other epidemics. “Try like hell to work with Haitian authorities, be confident that the folks like [Hospital CEO Dr. Maxi Raymondville]..... and the 6,400 other... folks are the best there is on the ground, some with 30 years experience fighting epidemics... Work on care protocols because that’s what the Haitian people expect of us. “Never accept second best as a policy goal,” he added.

It’s not an easy fight. Though it has taken on the role of a public hospital in Haiti, where the construction of the country’s rebuilt 534-bed General Hospital continues to be mired in construction overruns and delays, Mirebalais doesn’t receive any ministry of health funding. It relies on private funds and foundation support, which in recent years have declined along with other foreign donor money for Haiti. The U.S. Agency for International Development recently announced it was providing $16.1 million for Haiti to help it respond to COVID-19. None of that money is going to Zanmi Lasante. For now, the Haitian nonprofit is carefully managing its stock of available personal protective equipment, but that won’t be the case for too long, Farmer and others say. In Haiti, Viaud is looking to see if she can hire more nurses and quietly wonders as the disease rapidly spreads if she will find herself in the same dilemma as some hospitals in the U.S: forced to decide whether to devote the entire structure to COVID-19 patients.

Jacqueline Charles has reported on Haiti and the English-speaking Caribbean for the Miami Herald for over a decade. A Pulitzer Prize finalist for her coverage of the 2010 Haiti earthquake, she was awarded a 2018 Maria Moors Cabot Prize — the most prestigious award for coverage of the Americas.

Photo Credit: Miami Herald



Miami Herald

JUNE 08, 2020 

Cate Oswald, chief policy and partnership Officer for Partners In Health, speaks during forum on COVID-19 in Haiti The deadly novel coronavirus is so prevalent in Haiti, where a fever has been raging for weeks, that a top authority on public health is now saying there’s no need to test anymore to declare that someone is infected. That assessment is stirring debate in medical circles where some agree that providing symptom-based care is the way to go given the extent of the transmission, and others argue Haiti needs to ramp up testing to contain the spread.

The controversial view also has raised questions about whether Haiti, which has been struggling to manage COVID-19, is becoming so overwhelmed with the rapidly accelerating number of cases that it’s now taking a markedly different approach to the coronavirus than its neighbors and the World Health Organization’s “test every suspected case” directive to contain the spread of transmission.

Since Haiti confirmed its first two infections on March 19, the number of laboratory confirmed cases have spiked to 3,334 with 51 deaths in the population of nearly of 11 million. The country, however, has only tested 7,351 suspected cases — far less than the 94,000 performed in the neighboring Dominican Republic where there are 19,600 confirmed cases and 538 deaths in a population of roughly the same size. Both countries share the island of Hispaniola.

“All patients presenting with symptoms here have over 80 percent probability to have it,” Dr. Jean William “Bill” Pape, co-president of Haiti’s presidential response commission told the Miami Herald. “Almost all patients with [symptoms] of COVID-19 test positive. Hence no real need to perform the test.” Pape’s argument is based on his analysis, he said, of cases in the Port-au-Prince metropolitan region. The epicenter of the pandemic in Haiti, the capital region has 80 percent of the confirmed infections. Port-au-Prince is also where Haiti’s only two COVID-19 testing laboratories, GHESKIO, run by Pape, and the other by the government, are located.

A trailblazer in the fight against HIV/AIDS treatment in Haiti, Pape said he’s applying his past experience as a clinician treating acquired immune deficiency syndrome, to his approach with COVID-19, which is caused by the SARS-CoV-2a virus and can trigger mild to deadly respiratory tract infections. He was treating HIV positive Haitians at his GHESKIO research and health center for two to three years before a reliable test was available using, he said, just a clinical diagnosis.

Currently, he is treating 31 patients, including six physicians, who have COVID-19. With the exception of two who needed to be hospitalized for low oxygen saturation, all are being treated at home, said Pape, who on Sunday almost lost his downtown GHESKIO site to a raging fire.

“They all are able to monitor their oxygen saturation at home and we are expanding this technology in slums with community health agents. Hence it is necessary to expand a clinical definition of COVID-19,” he said. “It makes it possible to account for them and provide proper care to them. This is the case for all epidemics.”

Pape’s focus on curing patients rather than trying to find where they are to manage the course of the epidemic, has some fellow physicians and public health specialist wondering if Haiti is throwing in the towel because it cannot meet the growing testing demand as infections surge. Last month, Pape’s co-president on the commission, Dr. Lauré Adrien, who also is executive director of the Ministry of Public Health and Population, ignited controversy when he told Haitians that there is no “fever epidemic” spreading in the country. There is only COVID-19, Adrien said, and the high body temperatures Haitians are seeing should be automatically linked to the disease.

“They have lost control of the disease,” said Dr. Junot Félix, who runs a health consulting firm in Port-au-Prince and is a critic of the government’s response. “There is no other way to manage an epidemic than to test the people so that you can follow the virus...isolate them and trace and test their contacts.”

He called Pape’s clinical approach, and the declaration by Adrien that all fevers are linked to COVID-19, as “not making any sense.” “You can’t say someone has a fever and you give them medicine and don’t test them,” Félix said. ”The first thing you need to fight an epidemic is information...How are you going to manage an epidemic if you do know where the sick people are and how it’s moving?”

On Friday, the head of the government’s water agency, who had tested positive for the disease, revealed in a radio interview that after months of saying patients needed to test negative to be cleared, the health ministry had changed its protocol, according to his doctor. Patients can now resume normal activities after eight days with no symptoms, Guito Edouard said he was told.

Neither Adrien nor a ministry spokesperson responded to a Herald inquiry seeking confirmation of the change. Two members of the scientific cell advising the government’s response, said they are working on a recommendation to clear patients without a second test — which is still being done elsewhere in the Caribbean — based on studies on when someone is no longer considered contagious. The members acknowledged that Haiti, which has only managed to acquire 19,500 diagnostic tests so far, also does not have enough tests.

Haiti is still in the early stages of the pandemic, which experts say could peak this summer.But in just one month, the number of Haitians testing positive for the coronavirus has dramatically increased from 100 cases and 11 deaths on May 4, to 2,924 confirmed cases and 50 deaths a month later, on June 4.

The medical aid group, Doctors Without Borders /Medecins Sans Frontieres, said while the rise is alarming, the real infection numbers are most likely higher. Official statistics, for example, aren’t capturing those dying undiagnosed for the virus or whose deaths in rural and slum communities, after experiencing COVID-19 symptoms,

In recent weeks, woefully sick and dying Haitians have called the health ministry’s 2020 COVID-19 hotline pleading for help, only to refuse an ambulance from fear of being labeled with the disease by neighbors. Meanwhile, those seeking treatment at the few available treatment centers are arriving late and in critically-ill condition. “Unfortunately, a dozen patients have died on arrival at the hospital, and many others have arrived in critically ill condition,” MSF Mission Director Hassan Issa said about its Drouillard Hospital in the Cité Soleil shantytown.

Many with symptoms are not even going to the hospital for treatment, which Issa fears will only fuel the spread in communities and reduce individual’s’ chances of survival. Issa said the problem with Haiti’s official testing data is that it underestimates the extent of the disease in the country where the stigma faced by people increases their reluctance to get tested. He has no issues with Pape’s symptom-based care approach and said at this stage in the pandemic, the strategy “will make it possible to reduce the time taken for treatment and therefore save many more patients.”

Haiti’s Ministry of Public Health and Population has made no secret about its difficulties in tracing transmission of COVID-19 as uncooperative Haitians resist testing and even refuse to provide names of individuals they may have exposed to the disease from fear of being stigmatized. And for all intensive purposes, the government has lost the public relations battle in the fight against the virus. While officials have managed to get Haitians to increasingly cover up in Port-au-Prince, many Haitians are still not doing so outside of the capital and many still do not believe the disease is real, dismissing COVID-19 related symptoms as “a little fever.”

Even the basic message that most people infected with the virus will only suffer mild symptoms and will survive has become lost in the population. Haitians view the virus with shame, credit home-made herbal remedies for saving their lives, or blame anything but the coronavirus for their respiratory symptoms and other tell-tale signs of infections.

On Sunday, Twitter user Jhoane Boursiquot took to the social media platform to express her frustration over Haitians’ refusal to accept that COVID-19 is real. “I have a friend from Cap-Haïtien who I wrote to hear news from. He told me, he has a fever, all of his body, his throat ache, he’s lost his sense of taste,” Boursiquot tweeted in Creole. “He added that that they seem like symptoms of the coronavirus. I told him it is the coronavirus. He said, ‘No. It’s the fever.’ Oh Lord.”

Whereas most countries in Latin America and all in the Caribbean have enforced some form of mandatory lockdown to slow down transmission, Haiti has done no such thing despite extending a state of public emergency until July. There is no mandatory confinement. The government can’t even enforce its own rules banning large gatherings as mayors around the country complain about nightclubs being overrun with patrons despite an 8 p.m. to 5 a.m. nationwide curfew.

Without proof of infection, even the most well-informed Haitians continue to have a laissez-faire attitude toward the highly contagious disease as the population go about their daily lives without any social distancing or confinement measures. If for no other reason than to convince a population in denial, public health experts say Haiti can’t afford to give up on testing because it’s the only way to persuade Haitians to take the contagion seriously.

Haiti remains at high risk for a serious outbreak not just because of the population’s attitude toward the disease but the fact that thousands continue to pour into the country every week from the Dominican Republic, despite the closed borders. With more than 27,000 Haitians returning since the start of the outbreak, according to the International Organization for Migration, Haiti cannot afford to approach COVID-19 blindly, said Carlos Espinal, the director of the Global Health Consortium at the Robert Stempel College of Public Health at the Florida International University.

Testing and widespread testing, Espinal said, will allow health officials to know how the virus is moving, the speed of the transmission and what strategies they need to impose, especially in areas where the disease is most prevalent, to reduce the incidence and change the curve. “You cannot say, ‘Everybody who develops a fever in a country where malaria is so endemic, where you have cholera and many other diseases that produce fever, have COVID-19,” Espinal said. “You will have most of the population infected. It’s not possible to say that.”

The declaration by the health ministry’s Adrien, along with Pape’s clinical approach has led to chatter and concerns among some physicians about whether the country is deciding to go the way of the United Kingdom and Sweden, whose initial approach to the virus was to allow millions of their citizens to get infected in hopes of building a long-term resistance to the disease.

Espinal said such a policy, known as “herd immunity,” would be disastrous for Haiti, which “has a high risk of a serious outbreak” in the coming weeks. “At the present time we don’t even know if this virus will produce a solid strong immunity after infection,” Espinal said. “There is no proof of the concept to go for herd immunity and wait until you get 70 percent of the population infected to protect the people. There is not a lot of scientific evidence, so they really need to go into the testing of people and people with symptoms. And they need to make an effort to move out of the centralized [testing] area.”

Even as Haitians have resisted testing or lacked access, the number of suspected cases sent to the National Laboratory and Pape’s GHESKIO laboratory have been doubling each week. That also means that the number of available tests are quickly dwindling. At the current speed of 400 to 500 tests being run a day, Haiti would need access to enough kits to perform about 12,000 COVID-19 tests a month, experts surmise, if it were to decentralize testing and make it available in other cities outside of the capital.

Pape said there are currently 41 machines spread out across the country that could achieve this. But Haiti has nowhere near the required supplies, including reagents, a key chemical to test for COVID-19. The machines in question were donated by the U.S. Centers for Disease Control and Prevention to allow for one hour diagnosis of tuberculosis by polymerase chain reaction, the same technique used to detect the coronavirus and then confirm COVID-19. The machines can be used to diagnose COVID-19 in the countryside where today there are few laboratory confirmed cases.

CDC officials did not respond to a Herald inquiry on whether the agency was seeking to assist Haiti, which tried to order 5,000 additional tests from the United States only to have them blocked by President Donald Trump’s signing of the Defense Production Act, a government source said. The order prevents U.S. distributors from diverting personal protective equipment, or PPE, such as face masks and gloves and COVID-19 testing kits, overseas.

The U.S. Agency for International Development, one of Haiti’s biggest donors, said while it has given about $13.2 million in COVID-19 assistance to Haiti, “to date, USAID funds have not been used to procure reagents for COVID-19.” “But we are continually assessing the needs on the ground and adjusting our response during this pandemic in an effort to support Haiti’s needs,” said Acting USAID spokeswoman Pooja Jhunjhunwala.

As donors decide whether to help, frustrations over the lack of testing and the government’s haphazard approach grow. Félix, the physician, said many of the decisions being taken by Haiti “aren’t rooted in any logic, or data that they have.” “Take for example, the curfew they issued. No one can explain to me why there is a 8 p.m. to 5 a.m. curfew. Haitians don’t regularly go out at night. If it’s a problem with clubs, close the clubs,” he said. “Once 5 a.m. arrives, everyone takes to the streets and does what they want. Does this virus only function at night?”

Earlier this month, the Pan American Health Organization, the WHO’s regional office for the Americas, warned of a “pending humanitarian crisis” in Haiti. On Friday, PAHO said these concerns remain valid-to-date and re-emphasized PAHO Director Dr. Carissa Etienne’s call for all countries in the Americas region to ramp up testing so as to not lose control of the transmission. “The health system in Haiti has limited capacity to deal with an outbreak of COVID-19,” PAHO spokeswoman Ashley Baldwin told the Herald in a statement. “There are few beds for treating COVID-19, insufficient number of health care professionals and insufficient personal protective equipment. The security of the COVID-19 designated hospitals and the safety of community health workers is also of grave concern.”

Espinal, the FIU global health expert, said the situation in Haiti should be of concern for everyone. If Haiti can’t afford to access more tests, then PAHO needs to help, said Espinal, adding that the situation in the French-speaking Caribbean nation is akin to that of Nicaragua. PAHO has publicly chided leaders in the Central American nation for their lack of social distancing measures, and low test numbers.

“No one knows exactly what’s going on, but people are dying without diagnosis and no access to health care and there is very little that we know,” Espinal said of Haiti. “If they don’t have surveillance, if they don’t have data and if they don’t have any strategy on social distancing or mandatory confinement of the key areas where they are finding most of the cases, within weeks we will have a critical, chaotic situation in Haiti.”

Jacqueline Charles has reported on Haiti and the English-speaking Caribbean for the Miami Herald for over a decade. A Pulitzer Prize finalist for her coverage of the 2010 Haiti earthquake, she was awarded a 2018 Maria Moors Cabot Prize — the most prestigious award for coverage of the Americas.

10 June 2020

By Chandler Thornton and Etant Dupain


As Haiti's number of Covid-19 cases rises into the thousands, international agencies are sounding the alarm -- and so are some human rights activists. On Wednesday, Haiti's Health Ministry reported at least 3,662 confirmed cases and 56 deaths from the virus but humanitarian groups fear the number is far higher, due to a lack of testing. "There are currently only two laboratories in the country able to process COVID-19 tests," the international relief agency Médecins Sans Frontières (Doctors without Borders) said in a statement Thursday, warning " the issue of testing is increasingly becoming an important challenge to control the spread of the disease and provide adequate and timely care to those who test positive."

The group said Haiti faced unique challenges when it comes to containing the virus, namely, the difficulty of following social distancing measures and importing cases from neighboring countries.
"It has been impossible for most people to follow the measures, particularly those who live in the densely populated slums of the capital, where the highest number of cases have been reported," MSF said, adding that among the numerous challenges is also "the ongoing return of thousands of Haitian migrants from the neighboring Dominican Republic, which has the largest cluster of COVID-19 cases in the Caribbean, with more than 17,000 registered cases."

The World Health Organization (WHO) has also expressed worry. "We are very concerned about Haiti at the moment because of its unique circumstances, unique fragility and the fact that the disease is accelerating in a highly vulnerable population," WHO's Executive Director for Health Emergencies, Michael Ryan, said during a press conference last week. His remarks came after the Pan American Health Organization (PAHO) warned the spread of coronavirus in Haiti could result in widespread famine. "What has been common to many regions has been intense community transmission and it is clear that once community transmission has been established it's very difficult to root the virus out," WHO Director Ryan added. Meanwhile, the government's inconsistent response to the pandemic has raised questions. The country was put on lockdown to stop the spread of Covid-19 on March 19. However, a month later, the government of President Jovenel Moïse ordered businesses to resume production of manufactured goods, a key component of the country's export economy.

Then on May 21 as infections rose, Moïse announced sweeping new measures to prevent the spread of the virus. These prohibited any public gathering of more than five people, adding that those in violation would be fined 3,000 Haitian Gourdes (about $27) or possibly face a five-day prison sentence or a 15 days of community service. In addition, the president announced a curfew between 8pm and 5am daily.
The decree also included measures that appeared to have little to do with social distancing: Articles 14 and 15 prohibit taking and sharing photos or video of Covid-19 patients without their authorization, and strictly prohibit sharing on social media any images of bodies of people who died from Covid-19 -- under the threat of fine of nearly $200 or 15 days in jail.

A government spokesperson told CNN that the photography rules are aimed at preventing the "stigmatization" of coronavirus patients. But civil rights activists have criticized the decree as a threat to Haiti's democracy by limiting the spread of news and information. "This latest decree is very dangerous for our democratic process, the decree opens the door for all types of abuses," said Velina Elysée Charlier, an anti-corruption activist. "Today we're at a crossroads where we have to question the government's real motives. This decree will limit our freedom of speech guaranteed by the constitution."
The head of a local human rights organization also accused the government of trying to silence critical voices. "This decree is part of the Jovenel regime to not only crack down on protests and free speech but to put more people in jail, especially opposition activists," said Pierre Esperance, Executive director of Réseaux de défense des droits de l'homme, the country's largest human rights organization. Haiti's government has faced political unrest and protests for more than a year over allegations of corruption and complaints about soaring inflation.

"This is nothing new for anyone who's been following this president in the last three years," Esperance added. "He wants to scare people and control the flow of information to make them look good. This is one more attempt by this administration to consolidate power as they're failing to respond to the pandemic." The government did not respond to a request for comment on the criticisms, but has defended the strictness of its lockdown orders, saying they were necessary for public safety.
Haitian Foreign Minister Claude Joseph told CNN the government was "working to protect lives and contain the spread of Covid-19. Public safety during this time demands decisive action. We are announcing fines for actions which actively spread the virus - endangering the public." "This is a community-wide, nationwide effort and the vast majority of Haitians are doing the right thing and taking the necessary precautions to contain the virus - we want to help protect everyone by disincentivizing actions that could set us back," Joseph added.

But global public health experts warn that imposing jail time for those who violate social distancing rules may only make things worse. "Rather than support the population to mitigate the impact of this deadly virus, with this decree the Haitian government threatens the most vulnerable people with criminal action," said Dr Louise Ivers, Executive Director of Mass General Center for Global Health and Associate Professor at Harvard Medical School. "Already prisons in Haiti are overflowing with poor people, are inhumane and deadly grounds for infectious outbreaks," Ivers said.

13 June 2020

By Ivette Feliciano and Connie Kargbo

PBS News Hour

Dr. Jean William Pape has been on the frontline of Haiti’s ever-changing public health needs, from the early days of the AIDS epidemic to the devastating 2010 earthquake. Now, as the country’s fragile healthcare system confronts a massive uptick in coronavirus cases, Dr. Pape is using that past experience to fight yet another health crisis. NewsHour Weekend’s Ivette Feliciano reports.

Last year NewsHour Weekend profiled the unique resilience and persistence of Dr. Jean William Pape in Haiti. The doctor has been on the frontlines of Haiti's ever-changing public health needs and climate disasters, from the early days of the AIDS epidemic to the devastating earthquake in 2010. Now, as Haiti confronts a massive uptick in coronavirus cases, Dr. Pape is using that past experience to fight what is quickly becoming another health crisis in this fragile nation. 

Ivette Feliciano: Based on the last time we spoke with you last year in Haiti and learned a little bit about your history there, you've been on the front lines of the height of the AIDS epidemic and the earthquake aftermath and subsequent cholera outbreak. You know, how reminiscent is this moment and how much are you employing that knowledge right now?

Dr. Jean Pape: This type of knowledge is cumulative and it gives you huge experience, for instance. You know, it's been very difficult to convince many people, many Haitians, that COVID is real. So essentially, what we had to do is go in any community. And then we asked them to give us people that we could train as community health agents. We train them to sensitize their people, their population, where they live, about the disease, and to bring us anybody they feel have signs or symptoms associated with it COVID. You win that community immediately because poor people are not stupid. Poor people want to make sure that what you're telling them is real and what we're telling them is good for them.

Ivette Feliciano: But over the past few weeks Haiti has seen a rise of more than 600 percent of COVID-19 cases.

Dr. Jean Pape: We have a lot of Haitian leaving the Dominican Republic to return home, about 30,000 of them. And as you may know, the Dominican Republic has the worst epidemic in the entire region, they have passed the bar of 20,000 cases, so it's a huge epidemic. So we believe that those Haitians coming back, they are one now accounting for the disease spreading at the rate of 200 new cases everyday. We have essentially, have 24 more times the infection rate that we had three weeks ago.

Ivette Feliciano: In addition to community outreach strategies educating Haitians about COVID-19, Dr. Pape says large scale treatment centers are being set up around the country.

Dr. Jean Pape: We strongly believe that if we have enough patients who come in on time, they don't wait too long. We can save all of them. The tragedy has been young men in their 30s and some even younger, waited too long. And at that time, there's not much we could do for them.

Ivette Feliciano: But with about 21,000 tests for a population of 11 million, some doctors worry that Haiti is not testing enough people.

Ivette Feliciano: With only a limited number of tests, you know, how accurate are the official numbers of COVID-19 cases in Haiti?

 Dr. Jean Pape: What we've been doing is what is recommended by the WHO is essentially to test people with signs and symptoms. Nobody tests an entire population. So if somebody has signs and symptoms of COVID it is going to be tested.

Ivette Feliciano: So far the Haitian government has tested less than 11,000 suspected cases Dr. Pape says officials also haven't strictly enforced the national lockdown because for many Haitians, a day spent at home is a day without food.

 Dr. Jean Pape: The government has made some efforts to provide subsidies to families, but it's not sufficient. So, I am most afraid of the after COVID than the COVID itself because even if all the lockdown has not been implemented in Haiti, businesses have decreased a lot. Remittances from the diaspora have decreased by 30 percent. And the factories that are exporting to the U.S. have slowed down tremendously. We worry also because this year we've had a drought. So it's going to affect our crop at the end of this year, creating more hunger. And at all times, we're 40 percent of people who don't eat properly. So imagine that this is going to get worse.

Ivette Feliciano: In addition to the economic toll of the health crisis, Dr. Pape is also concerned about hurricane season which began just this month. He worries a big storm could make the COVID-19 outbreak even worse.

Dr. Jean Pape: When it rains badly, people die. Houses are destroyed. if you're putting people in some temporary shelter, you cannot have them too close one to another because you create an expansion of the COVID epidemic.

Ivette Feliciano: I want to ask, how are you feeling personally in this moment?

Dr. Jean Pape: Well, I think it's the toughest crisis I've been through. Essentially because it's coming at the worst time for us. At the time when we have five other major problems that would need a chapter on their own. So it's a combination of problems that make it a perfect, perfect storm.

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