COVID-19 in Haiti: Experts stumped by low toll, as normalcy returns

By Sam Bojarski and Samuel Louis

In Port-au-Prince, banks, stores and brick-and-mortar businesses have placed limits on in-person customers and continue to mandate masks. But many people walking the streets of Haiti’s capital are behaving as they did before coronavirus hit the country in March, ignoring mask mandates and social distancing guidelines from authorities. 

“When I saw how the pandemic roughly impacted some other countries, I thought it would destroy our country in a couple weeks,” said Jacob, 24, a student based in Port-au-Prince, who wished to keep his last name confidential due to fear of public backlash. 

Poor and lower-income Haitians, many of whom rely on daily, in-person transactions to purchase necessities like food, could never adequately practice social distancing, The Haitian Times reported in April. 

So as Jacob followed the daily statistics on coronavirus cases from Haiti’s Ministry of Public Health and Population (MSPP), he and many others expected to see a higher case count. 

Six months into the pandemic, however, many residents speak and act as if the coronavirus has come and gone in Haiti. Public health and medical experts continue to investigate why the toll has been so much lower than expected.

“There are still people testing positive through community transmission every day, but we have seen quite low numbers,” Elizabeth Campa, senior health and policy advisor for Zanmi Lasante, the Haitian affiliate of Partners in Health, said in early September.

Back in April, public health experts projected 1,000 deaths per day would occur by May in Haiti, whose population stands at more than 11 million. But the numbers recorded by the government have not come anywhere near these levels.

To date, Haiti has reported more than 220 deaths due to coronavirus since March and 8,646 confirmed cases as of Sept. 22, according to MSPP. Haiti’s curve showing growth in total cases began to stabilize in mid-July. The country has not recorded more than 100 new cases in a single day since July 15. 

At the height of the pandemic in April and May, the nonprofit health care provider Zanmi Lasante, recorded up to 300 coronavirus cases per day. Those numbers have since declined considerably in the past four months, according to Campa.

Medical experts from Zanmi Lasante and other health care providers continue to research why the coronavirus numbers have not come close to initial predictions. While their theories are not conclusive, they have identified age, climate and the particular strain of the virus that has infected Haitians as factors that could play a role.  

The economic toll

While lives have been spared, the pandemic has caused massive job loss and growing food insecurity. 

In March, after Haiti recorded its first case, the government closed factories, airports and schools to limit the spread. Textile factories and airports have since reopened, while teachers and students started returning to the classroom in August. But the combined toll of last fall’s political unrest and the coronavirus ‒ both of which depressed economic activity ‒ has strained parents’ finances.

“A lot of parents are now [going] broke, and they don’t have money to pay for schools,” said Jimmy Pierre, a school administrator in Kenscoff, a mountainous commune that lies six miles southeast of the capital. 

Government restrictions in place until July, such as passenger limits on tap-taps and the number of outdoor market days, have reduced income-generating activities. Irregular rainfall since late March and limited access to agricultural inputs have caused staple food prices to rise. Grain prices, for one, were about 80% higher than the five-year average this summer, according to a report by the Famine Earning Warning System Network (FEWS Net). 

Remittances ‒ a key source of income that accounts for about 34% of Haiti’s GDP ‒ were down by 9% compared to 2019, according to the FEWS Net report. 

The Global Network Against Food Crises, a European Union and United Nations entity, reported in September that as many as 4 million people in Haiti have faced acute food insecurity since COVID-19, an increase from the 3.7 million for all of 2019. 

Social unrest declined between April and June. But, the report’s authors predicted, unrest would worsen through early 2021, due to the declining economic situation. 

Raising awareness, building health care capacity

Jacob, the student in Port-au-Prince, said authorities disseminated safety messages well in the spring.

“I bought some face masks, hand sanitizer,” Jacob said. “It became a habit to wash my hands often.” 

Jacob added that he will adapt to the new status quo of mask wearing and personal hygiene measures.

But six months after Haiti recorded its first coronavirus case, the majority of people do not wear masks, according to Dr. Marie Deschamps, deputy director of GHESKIO. The organization helped lead President Jovenel Moïse’s commission to respond to COVID-19. 

Misinformation about coronavirus has spread through social media platforms. Health care workers have faced the threat of physical harm over concern that they might spread the virus. Coronavirus patients themselves also face the threat of physical retribution. 

In response, localized groups like Faith in Action, a network of religious leaders and elected officials in Haiti’s northeast department, took action. Faith in Action has spread educational messaging about sanitary practices via radio and in public marketplaces. The group also makes a concerted effort to encourage compassion and proper care for those infected, said Francois Pierre-Louis, Haiti director of Faith in Action International. 

The group’s engagement efforts have reached more than 35,000 people in the northeast. Educating people about how the virus is spread has helped decrease existing tensions, Pierre-Louis said.  

As community leaders, NGOs and government agencies disseminated messages, health care organizations ramped up capacity. In March, health facilities in Haiti had an estimated 124 intensive care unit (ICU) beds, with 62 ventilator machines for critically ill patients.

Contributions from the nonprofits Mission of Hope and USAID have since provided an additional 135 ventilators, combined, Deschamps said. And about 1,350 hospital beds for COVID-19 patients are available nationwide, although not all of them provide intensive care. 

“Most of the identified COVID-19 patients who visited the health centers in Haiti presented with mild [symptoms] and did not require the use of ventilators,” Deschamps said. 

Haitians who took coronavirus seriously this spring acknowledged how hard it was to follow public health protocols. One woman, a 22-year-old law student based in Port-au-Prince who identified herself as Yasminah, said her older brother, with whom she lives, is a police officer. 

Despite taking precautions, he fell ill, said Yasminah, who asked that her last name not be made public for fear of public backlash. 

Knowing the difficulty of avoiding neighborhood friends, who mingled with large groups of people, Yasminah was surprised Haiti did not record more coronavirus cases. Cases have been so uncommon that it made Yasminah question how real the virus is.

“I did not have any doubt before,” Yasminah said. “But the way things have evolved, it made me wonder.” 

Potential factors behind COVID-19’s spread

Medical experts do not yet have a clear answer as to why case counts and casualties have fallen short of initial predictions. 

Haiti’s low official death rate is likely an underestimate, said Dr. Mary Clisbee, director of research for Zanmi Lasante. But the numbers could be much higher and still not come near initial predictions, she said. Haiti has not recorded more than five deaths in a single day since Aug. 8. 

Haiti’s young population is one possible theory that has mitigated the severity of COVID-19, Clisbee said. Worldwide, the risk of dying from coronavirus increases significantly with age. About 54% of Haiti’s population is younger than 25 years old, with a median age of 23. 

The global median age is over 30 years old. 

Zanmi Lasante has undertaken multiple studies, in various stages of development. One internal study underway examines demographic clinical characteristics and outcomes among COVID-19 patients, according to Clisbee. 

The particular strain of coronavirus that has infected Haitians could also belie the country’s relatively low numbers. Another factor could be cross-immunization benefits from existing vaccines, Clisbee added, although no scientific evidence yet exists to back up these theories. 

Over the past seven years, the Haitian government has introduced routine childhood vaccines for pneumonia, a respiratory infection, as well as other diseases like diphtheria, hepatitis and whooping cough. 

Scientists have found that warmer temperatures could slow the spread of coronavirus. Warm weather, notably, cannot kill the virus. But Clisbee voiced skepticism that this factor alone has accounted for Haiti’s lower-than-expected numbers, citing high death rates in the southern U.S.

The state of Florida, by comparison, saw 20 straight days with at least 50 coronavirus deaths between Aug. 20 and Sept. 7. 

Despite the gradual swelling of crowded population centers in Port-au-Prince, where it is nearly impossible to maintain social distancing, the majority still live in a rural setting

Roughly 60% of Haiti’s population is rural, of which 25% is extremely rural, Campa explained, about Haiti’s population distribution. 

Testing is also limited, Campa said, given the short supply of chemicals and cartridges needed for polymerase chain reaction (PCR) testing in detecting the presence of coronavirus antibodies. This has made it difficult to estimate the virus’s true toll. 

But as of early September, she added, the widespread attitude among many Haitians was that the virus had come and gone. 

Yasminah, the law student, is one of numerous Haitians who said they have used natural medicines to boost their immune systems. Haitians have long used natural ingredients like sunflower leaves and ginger root, among others, to make herbal tea and ward off flu-like symptoms. 

Dr. Ralph Ternier, director of programs for Zanmi Lasante, said it is still early to claim an irrefutable benefit from any COVID-19 treatment. However, he said herbal teas can complement approaches like mask-wearing and social distancing.

In one May study, National Taiwan University researchers found that dietary therapy and herbal medicine could complement preventive measures. The findings, however, have yet to be validated by experiments on COVID-19 patients. 

GHESKIO continues to investigate hypotheses about the severity of coronavirus in Haiti. Deschamps noted age and preexisting conditions as factors that can impact the severity of the disease in a given population. 

The road ahead

Haiti might not be out of the woods quite yet when it comes to COVID-19. 

“There’s been discussions by infectious disease experts around the world that this fall, we may be seeing another wave,” said Campa, who noted the recent reopening of schools and resumption of normal activities in Haiti. 

Lack of funding from donors has adversely impacted the ability of Zanmi Lasante to provide testing and protective gear for health care workers, thus preventing health care organizations from preparing for future pandemics, Campa said.

NGOs, which operate more than 85% of schools and 70% of health care services in Haiti, face uncertainty going forward as well, as a result of COVID-19. 

In any given year, Hope for Haiti Chief Executive Officer Skyler Badenoch said, his organization raises $600,000 from in-person fundraising events. Among other initiatives, Hope for Haiti supports schools that serve more than 7,200 children in 24 communities. 

In lieu of its usual in-person events, Bardenoch said, “What we ended up doing was creating new revenue opportunities with online concerts, online auctions [and] virtual events.” 

One such event is the “Cheers to Haiti” virtual tasting and celebration, held on Oct. 14, in partnership with LS Cream Liqueur. While Bardenoch was optimistic, he said it remains unclear whether these virtual events will allow Hope for Haiti to meet its fundraising goals. 

Marie Victoire Alexis, 24, of Croix-des-Bouquets, said there is still concern about the adverse effects of coronavirus. But people are more worried about the ongoing political unrest and insecurity, she said.

Haiti has been plagued by rising gang violence this summer. Within the past month alone, protesting police have shut down Port-au-Prince, teachers have protested low pay and poor working conditions, and college students have protested against shooting deaths — all against the backdrop of the global pandemic. 

“The insecurity is really strong right now, here in Haiti,” Alexis said. “Many people are worried [or] scared about what will happen or what will come next.” 

Samuel Louis contributed reporting from Port-au-Prince, Haiti.