Tuberculosis, poverty, and "compliance": lessons from rural Haiti

Tuberculosis (TB) is the leading cause of death among rural Haitian adults, and TB control in Haiti is widely acknowledged to be a failure. The causes of both the endemicity of TB and the failure of attempts to address it are briefly reviewed before data from a study conducted in rural, central Haiti are presented. Members of one group of patients with active TB were given free medical care; members of a second group were given free care as well as financial aid, incentives to attend a monthly clinic, and aggressive home follow-up by trained village health workers. Comparing the two groups shows significant differences in mortality, sputum positivity after 6 months of treatment, persistent pulmonary symptoms after 1 year of treatment, average amount of weight gained, ability to return to work, and cure rate. The roles of human immunodeficiency virus and cultural factors are also examined. When adequate nutrition and access to free care were assured, drug-dependent and patient-dependent factors were shown to be of secondary importance in determining treatment outcome. Based on these data from a small, community-based TB-control project, the authors conclude that high cure rates can be achieved if the primacy of economic causes of TB is acknowledged and addressed.

High prevalence of antibodies to the gp120 V3 region principal neutralizing determinant of HIV-1MN in sera from Africa and the Americas

Neutralizing antibodies (NA) against HIV-1MN and HIV-1IIIB, and antibodies binding to synthetic peptides (BA) derived from the gp120 envelope V3 region principal neutralizing determinants (PND) of the HIV-1MN, HIV-1IIIB, and HIV-1Z3 virus strains were assayed in HIV-1 antibody-positive sera from the United States, Haiti, Brazil, Zaire, and Zimbabwe. The ability of soluble PND peptide to block neutralization of the corresponding virus by representative sera was also tested. In each country, NA and BA titers were highest against the HIV-1MN strain, and compared with other countries, NA and BA titers against HIV-1MN were higher in sera from the United States and Haiti. When NA titers were compared with BA titers against either HIV-1MN or HIV-1IIIB, no correlation was found for the HIV-1IIIB strain, but there was a significant correlation for HIV-1MN. Addition of the HIV-1MN strain peptide to a neutralization assay for HIV-1MN resulted in a four- to tenfold reduction in NA titers in sera from the United States, Zaire, and Brazil. The results suggest that HIV-1MN and closely related variants are prevalent in many parts of the world, and that antibodies directed against the PND account for most of the neutralizing activity in sera of infected individuals.

Perceptions and practices relating to condom use among urban men in Haiti

This report is based on a survey conducted in 1986-87 of sexually active adult male residents in a low-income community of Port-au-Prince, Haiti. The objectives were to investigate knowledge of and attitudes toward condoms; to evaluate the effectiveness of the existing condom distribution program; and to obtain information that can be used in the design of strategies to increase condom acceptance and use among men throughout Haiti. A final sample of 706 sexually active adult male residents in stable unions, including a specially drawn sample of male partners of condom acceptors, were interviewed in their homes. Although condoms are almost universally known, they are rarely used. The majority felt that the responsibility for family planning should be borne by the woman. Whereas condoms may be of limited popularity for family planning purposes in Haiti, it should be determined whether they might be more acceptable as an effective means of controlling the spread of AIDS and other STDs.

The Quality Assurance Project: introducing quality improvement to primary health care in less developed countries

Persistently excessive morbidity and mortality rates in less developed countries (LDCs) served by primary health care systems suggest that the quality of services is inadequate. The PRICOR project, sponsored by the United States Agency for International Development, has designed and implemented methods for quality assessment and problem solving in LDC health systems. After developing comprehensive lists of essential activities and tasks, similar to practice parameters, for seven child survival interventions, PRICOR supported comprehensive quality assessment studies in twelve LDC countries. The studies, yielding over 6000 observations of health worker-client encounters, indicated highly prevalent, serious program deficiencies in areas including diagnosis, treatment, patient education and supervision. To facilitate corrective action, PRICOR assisted managers in conducting operations research to resolve priority problems revealed by the assessments. The recently initiated Quality Assurance Project is building on PRICOR techniques in designing and implementing sustainable continuous quality improvement programs for LDC health systems.

["To find life": migration and subsistence strategies in the Haitian peasantry]

"The objective of this article is to present briefly some results of two research projects on migration and the subsistence strategies of Haitian households. Fieldwork for these two projects were undertaken in Haiti (1982) and French Guyana (1986-1987). The methodology is mainly qualitative and the collection of life histories constitutes the main data source." The author notes that "the increasing social and economic marginalization of the peasant population, the exodus of the young labor force, and the educational and migratory strategy of parents for their children are all but a few factors which transform the traditional peasant mode of living. Given the actual state of the economy and polity in Haiti, emigration generates emigration." (SUMMARY IN ENG)

Weight gain variation in infants of an impoverished community: Bellanse, Haiti

Maintaining adequate growth remains one of the most difficult tasks for infants in developing countries. A cohort of rural infants (n = 354), median age four months, were weighed every 6-7 weeks over an 18-month period. Some 179 infants (51%) with weight information over at least 12 months were included in the study. The association between weight gain up to 6 months of age, and between 6 and 23 months of age, and factors amenable to prevention were assessed using weighted multiple linear regression. Infants whose mothers understood the 'Road to Health' chart had a weight gain that was 123 g/month (95% confidence interval (CI): 2-245) higher up to six months of age and 31 g/month (95% CI: 6-57) higher between 6 and 23 months of age compared to infants whose mothers did not seem to understand the chart. The weight gain between 6 and 23 months was also 28 g/month (95% CI: 3-54) higher for infants fully vaccinated at 11 months compared to not fully vaccinated children. It was 47 g/month (95% CI: 16-78) higher for infants living in two-parent families compared to children of a single-parent family. The results of the study suggest that maternal comprehension of the 'Road to Health' chart may contribute to more adequate weight gain.

Educating factory workers

There are approximately 50,000 workers employed in the light assembly industry in Haiti. About 70% are women, the majority of whom are aged between 25 and 34 years, and are either single or in a nonpermanent relationship with the father of their children. Many live and work in appalling conditions, surviving on very low wages to support several children and an extended family. The acquired immunodeficiency syndrome (AIDS) is now a visible problem in many factories. In October 1988, the Center for the Promotion of Women Workers (Centre de Promotion des Femmes Ouvriers/CPFO) launched a pilot AIDS education program for factory women. The Center, based in a large industrial zone near the airport, runs a health clinic and courses in literacy, communications skills, health promotion and family planning. The new AIDS program allowed CPFO staff to gain entry into factories for the 1st time. Other courses were held outside working hours and outside factory premises. Staff contacted manages by telephone to arrange a meeting to discuss AIDS and to ask permission to hold educational "round tables" with workers. Of 18 managers in the factories approached over a 12-month period, only 2 refused entry to CPFO staff. Almost all managers reported they had registered between 2 and 5 deaths from AIDS among their employees over the past couple of years. A total of 85 educational sessions, each lasting about 2 hours, were held within 28 different factories, community or labor organizations reaching 3063 workers (male and female). In each session, the presentation was carried out by 2 CPFO trained monitors and included a slide show, flip charts, and the video "Met ko," originally produced for Haitian immigrants in New York. The most important aspect of the program was the training of 38 volunteer factory-based health promoters. These promoters attended the round table sessions, where they facilitated discussion and distributed condoms and were subsequently available for counseling co-workers. Initially, the Center intended to recruit only literate women as promoters, but several nonliterate women were selected for training by labor organizations 18 hours of tuition and discussion of AIDS/human immunodeficiency virus were held over 2 1/2 weeks, including sessions on group dynamics and organizational skills. To improve communications skills, sessions included role play exercises which were videotaped and played back to trainees. Training in communication skills also helps promoters participate in activities aimed at supporting a broader range of workers' rights.

Knowledge, attitudes, beliefs and practices related to AIDS among Montreal residents of Haitian origin

We used interviews of 268 subjects to ascertain knowledge, attitudes, beliefs and practices related to AIDS among Montrealers of Haitian origin, from November 1987 through October 1988. The questions on knowledge included items on general knowledge about the disease (prevention of AIDS, treatment, nature and manifestations of the disease, screening and high-risk groups), and more specific questions about modes of HIV-1 transmission. The average correct answers to questions on general knowledge about AIDS was 81%. The questions on HIV-1 transmission concerned both modes of infection that are scientifically established, and other modes that are not scientifically recognized. The average correct answers to questions on scientifically recognized modes of infection was 94% and the average correct answers for modes of transmission that are not scientifically accepted was 74%. The attitudes and beliefs of Montrealers of Haitian origin toward persons with AIDS was only moderately favourable. Attitudes and beliefs toward condom promotion were very positive. The percentage of subjects reporting male homosexuality or injection drug use was extremely small. 23% of subjects who had experienced sexual intercourse reported that they had two or more partners during the 12 months preceding the survey.

Insertion site complications during the first year of NORPLANT use

Although review articles have provided much information on the NORPLANT system, information on insertion site complications based on multi-country trials has been limited to infection rates. This paper examines 2,674 NORPLANT acceptors from seven countries who were enrolled and followed for one year. The one-year incidence rates of infection (0.8%), expulsion (0.4%) and local reaction (4.7%) varied widely among countries and clinics within a country. In contrast to previous reports that insertion site complications occur during the first few weeks of use, these data show that a substantial proportion of insertion site infections (34.6%) and implant expulsions (64.3%) were reported after the first two months of use, while 35.7% of local reactions were reported after 4.5 months of use. Of the 16 women with infections who did not have the implants immediately removed, 8 eventually required or requested removal, indicating that the ICCR recommendation for immediate removal in case of infection appears appropriate. An awareness of the frequency of insertion site complications, distribution of the time of onset post-insertion and potential sequelae of complications will aid clinicians in better client counseling and complication management.

Health beliefs related to diarrhea in Haitian children: building transcultural nursing knowledge

Regardless of where they live or under what circumstances, mothers throughout the world seem to have a compelling desire to provide the best possible health care for their children (Huston, 1979). Haitian mothers living in the Dominican Republic were no exception. The health beliefs and practices of these mothers related primarily to diarrhea among their children which demonstrated a concern and resourcefulness that is commendable. The results of this study clearly indicate the importance of transcultural nurses conducting culturally relevant research as a basis to develop sound health programs in developing countries. Diarrhea was identified as the single most important threat to a child's health in these communities. That mothers did not know about the correct ingredients and/or proportions for oral rehydration solutions (Western views) was of interest. Although the Dominican government makes some commercial packets of ORS, most of the women interviewed did not have ready access to this product. This finding reflected the need for transcultural nurses to offer to teach mothers how to make ORS using the sugar, salt, and water they had available. Since the mothers' perception that diarrhea was a dangerous threat to their children's health, was verified by childhood mortality statistics in the bateys, it would seem that ORS could make a significant impact on the health status of the children. Breastfeeding also was a major health belief factor associated with the treatment of diarrhea. Even though the majority of mothers believed breast feeding should be continued if a child had diarrhea, a number believed it should be discontinued. Nurses working with CHWs will need to emphasize the importance of breastfeeding and help them to develop creative ways of communicating this information to the mothers. The second most dangerous threat to the child identified by the mothers was respiratory ailments. This suggests a new area of concentration for future research and training of CHWs. A host of new questions related to respiratory problems such as health beliefs, causative factors, course of disease, traditional treatments, mortality rate, etc. need to be investigated. When transcultural nurses plan health care programs for women and children in other cultures, it is important to recognize the concerns mothers have for their children, and their intense desire to nature and care for them. In this study, mothers willingly participated and demonstrated active interest in learning to use methods to improve the health and well being of their children. It is well documented (Lieban, 1977) that established health beliefs are not automatically discarded when new knowledge is made available, but that exploration and incorporation of new information when presented in a culturally relevant framework does occur. An understanding of local beliefs surrounding health is fundamental to the development of appropriate transcultural nursing interventions.

HIV and HTLV-I infections in the Americas: a regional perspective

With over 143,000 cases of AIDS reported to the World Health Organization from 145 countries and with an estimated 5 to 10 million people worldwide infected with HIV, AIDS has become firmly established as a global pandemic. In the region of the Americas over 100,862 cases of AIDS have been reported with indigenous transmission documented in 45 to 46 countries. While North America has the highest annual number of AIDS cases per population, with 72 cases/million, the Caribbean subregion has a disproportionately high number of cases, with annual rates as high as 200 to 300 cases/million population for some countries. Despite differences in absolute number of cases, there has been a remarkable similarity in the temporal rate of increase of AIDS in the countries of the Americas, reflecting delayed introduction of the virus to some areas with an early exponential increase similar to that observed initially in the United States. Although the modes of transmission of HIV are the same throughout the region, evidence of increasing bisexual and heterosexual transmission, particularly in the Caribbean subregion, has resulted in a lower male-to-female ratio of AIDS cases and increased perinatal transmission. Clinically, a resurgence of diarrheal diseases, respiratory infections, and tuberculosis has been documented in association with HIV infection in many tropical countries of the Americas. With relatively high rates of HTLV-I infection already established in the Caribbean subregion, the overall public health problems of the Americas will be markedly potentiated by further spread of these 2 human retroviruses. If HIV infection continues to penetrate the poor and less advantaged populations in Latin America and the Caribbean, the potential exists for a massive epidemic in the Americas that may rapidly parallel the situation in Africa.

Use of ethnographic research for instrument development in a case-control study of immunization use in Haiti

A rapid ethnographic assessment of barriers to health service utilization was conducted to identify maternal factors predicting use of child immunizations in Haiti. Methods included four focus group interviews, four natural group interviews, individual interviews with 14 health care providers and participant observation at vaccination posts. Analysis of qualitative data identified five categories of maternal factors associated with immunization use: competing priorities, low motivation, socioeconomic constraints, perceived accessibility of services, fears about health or social consequences and knowledge and folk beliefs related to vaccines. Selected variables among these factors were incorporated into a survey instrument designed to compare mothers of completely vaccinated children (cases) with mothers of incompletely vaccinated children (controls). The questionnaire was administered to 299 randomly selected mothers (217 cases, 82 controls). Bivariate and multivariate analyses found that of the factors identified through ethnographic research, only vaccine-related knowledge was significantly associated with immunization status. The utility and constraints of using ethnographic research for instrument development in epidemiological studies are discussed.

Decree of 14 November 1988

This Decree amends Article 55 of the Haiti Civil Code to authorize the mother of a child to declare the birth of the child at the Civil Status Office if the father does not make the declaration. It also provides that, if the declaration is not made within two years of the month of delivery, an Officer of Civil Status may not enter the birth in the register unless a court authorizes the entry. Proof of civil status may be of any sort legally recognized. Further, the Decree requires all persons without birth certificates to regularize their civil status within five years of the promulgation of the Decree and requires a birth certificate to be produced for persons being baptized or "presented at the Temple."

Order defining the jurisdiction of the forestry guard, 30 December 1987

This Order defines the jurisdiction of the Haitian forestry guard in order better to protect the State's hydrographic basins and national forest resources. It provides that the forestry guard is to have the following functions: 1) to oversee in general the application of forestry legislation; 2) to stop all forms of agricultural or forestry exploitation that harm state lands; 3) to confiscate all illicitly exploited forestry resources; 4) to inspect regularly the parts of the forest or parks assigned to its care; and 5) to control the circulation of wood and wood products, documents, and freight. In collaboration with other interested state agencies, the forestry guard is also to prevent forest fires and promote the natural and man-made generation of the forest.

Decree of 30 August 1988

This Haitian Decree abolishes the status known as "civil death" whereby a person was convicted of serious crimes and deprived of all legal personality while physically still alive. The Decree also abolishes, as a ground of divorce, the existence of "civil death" on the part of one of the spouses.

Women's status and family planning in Haiti

"The paper argues that women's status in Haiti is a factor favorable to the spread of modern contraception and a potential rapid demographic transition from high to low fertility. After briefly reviewing recent theories on the determining of fertility declines, the paper considers women's status in Haiti. It discusses family patterns, conjugal unions, and economic activities. Finally, it reviews current patterns of contraceptive use and considers how these are related to various aspects of women's status."

The acquired immunodeficiency syndrome in Haiti

Two hundred twenty-nine patients in Haiti with the acquired immunodeficiency syndrome were studied between 1979 and 1984. The clinical spectrum of the syndrome in Haitians was similar in most aspects to that in patients with the disease in the United States. However, in contrast to findings in the United States, accepted risk factors (bisexuality, blood transfusions, intravenous drug abuse) were identified in only 43% of Haitian patients. Patients in Haiti with and without these risk factors were similar to each other but differed from age- and sex-matched siblings and friends in the number of heterosexual contacts and receipt of intramuscular injections. These latter activities were commoner in patients than in their siblings and friends, and represent potential modes of transmission of infection with the human T-lymphotropic virus type III.

The international occurrence of the acquired immunodeficiency syndrome

Through December 1984, 9932 cases of the acquired immunodeficiency syndrome have been reported, mainly from North and South America and Europe; 85% of these cases occurred in the United States. Haiti and the United States have the highest incidence rates, 59 and 36 per million population, respectively. Rates in the United States range from 0.3 (beginning of 1981) to 10.4 (end of 1984). Brazil, Canada, Denmark, Switzerland, France, West Germany, the United Kingdom, and the Netherlands show a slower increase. Homosexual men and intravenous drug users are still the main risk groups in the United States and Europe. The disease is prevalent in heterosexual Haitians and Africans whether they live in their own countries or abroad. Cases of the syndrome have been identified in Zaire, Rwanda, Zambia, and Uganda, but its full extent is not yet known. Consistent with the general history of epidemics, the appearance of geographically separated sites of incidence of the syndrome could be linked to population migrations; however no evidence has been found to identify an index location.

[Haitians in Montreal: demographic and spatial evolution]

"Analysing demographic characteristics over a given period may be useful in explaining the spatial distribution of ethnic groups in an urban environment. This paper first presents the main aspects of the demographic evolution of Quebec's Haitian population during the 1971-1981 period. It then analyses the evolution of the spatial distribution of this population in the Montreal region. It finally tries to show the interrelations between both evolutions." (SUMMARY IN ENG AND SPA)

[Class, sex, and socio-professional trajectory: the case of Haitian immigration to Quebec]

"Various studies have shown the role of Haitian immigration in satisfying the need for manpower in Quebec. Very few, however, analyse the process which leads immigrants to this role. This paper shows that sex and class in the country of origin strongly determine the socio-professional trajectory of Haitian immigrants in Quebec. These two factors define indeed a specific process of skill acquisition, and, therefore, a more or less strong bargaining power on the labor market." (SUMMARY IN ENG AND SPA)

Haiti seminar discusses voluntary sterilization

Devising strategies to meet the growing demand for voluntary sterilization in Haiti was a major topic of discussion during a week-long seminar November 28-December 2 organized by the Division of Family Hygiene (DHF) of the Haitian Department of Public Health and Population. More than 30 physicians trained in laparoscopy and minilap who provide services through the DHF program met to summarize progress and discuss problems of the program to date, review technical aspects of female sterilization, introduce technical aspects of vasectomy, and set goals for 1984. FHI provided 2 consultant-speakers for the seminar, Dr. Lise Fortier, medical director of Planned Parenthood of Los Angeles, and Dr. Liliane Toumi, consultant for training in male and female sterilization. The DHF has given high priority to its voluntary sterilization program, which has recorded a slow but steady increase in the number of individuals sterilized since its beginning in 1979. Postpartum minilaps account for the highest percentage of procedures (69%) of cases reported to the DHF in the 1st 1/2 of 1983), with most of the remainder consisting of laparoscopy. In 1983, there was also an increasing emphasis on vasectomy, accounting for 5% of all cases reported in the 1st 6 months. 3 physicians attending the seminar had just returned from Sao Paulo, Brazil, where they were trained in vasectomy by Dr. Marcos de Castro. An additional 3 are scheduled for training in Sao Paulo early this year. These 6 physicians will form the basis of an in-country vasectomy training program for their colleagues. Data from an ongoing FHI Maternity Care Monitoring pilot project at Hopital Universitaire de l'Etat d'Haiti support the observation of physicians at that center that 65%-70% of potential candidates for sterilization there are not sterilized. Discussion at the seminar identified the following possible reasons for the unmet need for sterilization: requirements for laboratory tests, lack of space for procedures and recovery, irregular supplies, and need for better patient education and motivation during the prenatal period. 1 suggestion to increase the access of rural populations outside of Port-au-Prince was to offer sterilization services through mobile clinics operating out of health centers around the country. FHI is continuing its assistance to the DHF program by helping to establish reporting and to maintain data on sterilizations performed throughout Haiti. Initially, the Division will use FHI female sterilization and male sterilization patient summary forms for monitoring cases in the 6 centers doing a large proportion of the procedures. The consensus of those attending the seminar was that a strong voluntary sterilization program is of the utmost importance in meeting Haiti's family planning needs.

Haitian emigration in the early twentieth century

"Standard migration theories see receiving countries as the dynamic agent [pulling] migrants to them. These theories, while useful for explaining many cases, appear inadequate for the case of labor migration from Haiti to Cuba and the Dominican Republic in the early twentieth century. This article examines this history and offers an alternative theoretical framework for explaining this migration flow. It is argued that the prime cause of migration from Haiti is factors in the sending country."

Characteristics of the acquired immunodeficiency syndrome (AIDS) in Haiti

To identify the characteristics of the acquired immunodeficiency syndrome (AIDS) as it occurs in Haiti, we studied 61 previously healthy Haitians who had diagnoses of either Kaposi's sarcoma (15), opportunistic infections (45), or both (1) established in Haiti between June 1979 and October 1982. The first cases of Kaposi's sarcoma and opportunistic infections in Haiti were recognized in 1978-1979, a period that coincides with the earliest reports of AIDS in the United States. We do not believe that AIDS existed in Haiti before this period. The types of opportunistic infections and the clinical course in Haitians with Kaposi's sarcoma and opportunistic infections were similar in most aspects to those in patients with AIDS in the United States. The median age of Haitians with Kaposi's sarcoma and opportunistic infections was 32 years, and 85 per cent were men. The interval between diagnosis and death was six months in 80 per cent of the patients. Diarrhea was the most common reason for seeking medical attention in patients with opportunistic infections. Lymphopenia and skin-test anergy were observed in 86 and 100 per cent of patients, respectively. Potential risk factors (bisexual activity or blood transfusions) were identified in 17 per cent of male and 22 per cent of female patients. Demographic information suggests that patients belonged to all socioeconomic strata of Haitian society.

Plants of Haiti used as antifertility agents

Haitian empirical medicine sprang from both European (16th to 19th century) and African (especially voodoo) traditional therapies. The use of medicinal herbs is highly developed. Our purpose was to list the plants held to be antifertility agents in the island. We identified about twenty species more or less currently used by the women as abortifacients or emmenagogues. The chemistry and active components of a few species are well-known. However, for most of them, some were partially studied, and no relation could be established between their chemical composition and their potential activities, and the rest are chemically unknown. We chemically screened extracts of Casearia ilicifolia, Eleutherine bulbosa, Rhoeo spathacea and Stemodia durantifolia, and identified flavonoids, triterpenes and sterols in the leaves of C. ilicifolia, and naphthoquinones, and a new anthraquinone, anthracene-9,10-dione-1,5-diol-4-methoxy-3-methyl-2-carboxylic acid methyl ester, in the bulbs of E, bulbosa. R. spathacea showed a stimulative activity on mouse uterus. Antifertility screening tests of C. ilicifolia and E. bulbosa showed activity in rats, but also probably toxicity.