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Remarks by Loune Viaud, Executive Director, Zamni Lasante

University of North Carolina Annual Water and Health Conference

October 17, 2017

Hello everyone, and thank you for the wonderful introduction.

As you just heard, I stand before you today not as a doctor, or a water systems engineer, or a WASH professor. I’ve worked with Partners in Health to provide public health services to the Haitian people since the 1980s. Today, I’m here to talk about the successes we’ve seen over the decades, the challenges we still face, and the need of providing clean water to vulnerable populations worldwide.

I want to begin with a story, so please bear with me. In 1998, the Inter-American Development Bank (IDB) agreed to send a loan and a grant to the Government of Haiti to be spent on water and sanitation, with a goal on improving the quality of life of women and children. Over the next several years, the government of Haiti ratified the loans and met the contractual requirements, including paying outstanding debts to the IDB. One of the first proposed projects under the loan was intended to be the establishment of a potable water system for Port-de-Paix, a city located on the northernmost tip of Haiti. The city’s water system at the time did not come close to meeting the population’s needs or WHO’s safety standards.

However, in 2001, the United States government expressed “significant concerns” regarding the loan, halting its disbursement. Through a lawsuit under the Freedom of Information Act, we learned that these so-called “concerns” had nothing to do with the Haitian government’s ability to pay back the loan, the demonstrated need for the project, or the quality of the plans for the water system. Instead, the U.S. government wanted to halt the loan until the Haitian government met specific political benchmarks unrelated to the loan or the proposed WASH projects. While withholding loans based on political goals was not permitted under the IDB’s Articles of Agreement, and even though the Haitian government paid $32 million in outstanding debts to the IDB in order to secure the loan, work did not begin on the Port-de-Paix water system for almost a decade after the loan was initially approved, leaving residents without safe water and sanitation during that time.

Port-de-Paix is not an exception. Rather, it demonstrates a rule that has defined much of the Haitian existence. Development projects make big promises and sign big checks, but on-the-ground realities often don’t match up with discourse at the policy level. Life in Haiti is many things—colorful, beautiful, rich with culture and strength and resilience. But without access to healthcare, clean water, and basic services, it can also be very, very hard.

According to the World Health Organization, the population of Haiti has been repeatedly denied the right to safe water, sanitation, and hygiene. Although improved WASH services have the potential to prevent almost 10% of deaths in Haiti, only 62% of the Haitian population currently has access to an improved water source, while only 31% has access to improved sanitation facilities. In rural populations, these already low numbers drop to 47% and 16%, respectively. Conversations about public health in the developing world are often overwhelmed with dramatic statistic after statistic, but take a moment to think about that one—the World Bank told us that less than two of every ten Haitians living in rural areas have access to acceptable sanitation resources. To a room full of global WASH experts that might not be a shocking number, but it should be. In a world of increasingly precise medicine and advanced public health technology, ensuring that everyone has access to basic water, sanitation, and hygiene should be an achievable priority. Don’t you all agree? Instead, between 1995 and 2010, Haiti was the only country of 161 with available data that saw a decrease in access to sanitation facilities for reasons other than population decline. Although that data is partially distorted due to the catastrophic earthquake that struck in 2010, sanitation coverage had already dropped significantly between 1990 and 2008, two years before the earthquake. These trends tell us that WASH is not improving on its own—we must fight to improve it. Given Partners In Health’s experiences in the field relative to education and health facilities, we see the effects of the lack of WASH infrastructure and waterborne infections, making accessibility to healthcare more difficult or complicated for health workers.

Safe WASH practices are particularly necessary in the sphere of gender, one of the themes of this week’s conference. Although a lack of access to WASH is always dangerous, it has a particularly dire effect on women and girls in developing nations. For example, women and girls are usually the ones who fetch water for their families, which takes time away from studies and jobs and can be especially dangerous at night. Women experience sexual harassment and violence when using mixed gender bathrooms, suffer due to a lack of clean menstrual hygiene materials, and risk infection or worse when giving birth in areas without access to clean water. Some women wait until dark to go to the bathroom in areas where shared public restrooms are unsafe for them, again putting them at greater risk for sexual harassment and violence. Finally, women are usually the main caregivers of family members who contract water-borne illnesses, taking time away from other activities and putting them at risk of falling ill as well.

For these and other reasons, WASH is particularly relevant to the wellbeing of women and girls. States are required to protect women’s right to adequate living conditions—including water and sanitation—under the Convention on the Elimination of All Forms of Discrimination Against Women, which was adopted in 1979 by the United Nations General Assembly and ratified by Haiti in 1980. Other international conventions—including the International Covenant on Civil and Political Rights and the International Covenant on Economic, Social and Cultural Rights—similarly protect the right of women and girls to enjoy adequate water, sanitation, and hygiene resources. And yet women continue to be disproportionately affected by unsafe WASH in Haiti and around the world.

I’m so glad that another theme of this week’s conference is water in non-household settings because much of what we do at Partners In Health in Haiti is based around providing services in these contexts. Non-household settings such as schools and healthcare facilities are the centers of many communities—sources of trust and places of gathering. Providing safe water and sanitation in these locations is vital to the success and future of the entire community. Our 12 health facilities all have access to appropriate WASH facilities and our network of schools provides about 12,000 children with proper access to WASH infrastructure.

Without proper WASH at schools, girls must miss class during menstruation. Others choose not to attend to avoid the embarrassment or shame of using shared bathroom facilities. Children who contract water-borne illnesses from unsafe drinking water at school miss lessons, fall behind in their studies, and sometimes cannot catch up. Perhaps most importantly, children who are sick and thirsty, simply can’t learn well. In 2014, Partners In Health conducted an analysis of 42 schools in Haiti’s Central Plateau and found that none had adequate facilities for menstruating girls. More than 90% of schools in the Central Plateau don’t have adequate WASH resources. One in four children in Haiti has intestinal parasites, which drain energy and make it difficult to focus and study. The privacy, dignity, health, and future of Haiti’s children is at risk with every trip to the bathroom and every sip of water they take at school. This is unacceptable.

Health facilities such as clinics and hospitals, where one would expect to find the highest level of sanitation standards, are also unable to provide safe WASH to most Haitians. In a country with the highest rates of tuberculosis in the western hemisphere and with an HIV prevalence of almost 2% in adults aged 15 to 49, providing already sick patients with safe water and reliable sanitation and hygiene is essential. However, unfortunately, that isn’t the reality in many cases. In 2014, Haiti’s Ministry of Public Health (MSPP) reported that less than half of all health centers in the country had proper sanitation facilities, and 30% had no access to an improved water source. Global data is similar: WHO and UNICEF reported in 2015 that in low- and middle-income countries worldwide, more than a third of health centers don’t have improved water sources or proper handwashing materials. When sick people arrive at a health facility, often after walking for hours, they should be confident that the space will offer them safe water, appropriate WASH infrastructure. But in Haiti and many other nations, this is simply not an assumption one can make.

There is much work to be done in order for Haitians to have reasonable and reliable access to clean WASH resources. How, then, have development and humanitarian agencies, international donors, and public health experts been working together to begin to improve WASH in Haiti?

Numbers differ depending on the report, but money donated to Haiti following the 2010 earthquake numbers in the billions. During the emergency phase in the year directly following the disaster, approximately 13 billion dollars was pledged or disbursed for relief and recovery by official bilateral and multilateral donors according to the UN Office of the Special Envoy for Haiti. That’s equivalent to 400 percent of the Haitian government’s own internal revenue in 2010. Of that monumental amount of money, less than one percent reached the Haitian government itself. Meanwhile, over half was promised or given to United Nations agencies and international NGOs. It is important to understand that 51% of all NGOs working in Haiti are headquartered in the United States, while only 21% are Haitian based. And the number of Haitian NGOs included in the initial post-earthquake appeal? Almost none.

It is often said that the Haitian government must be more accountable, more transparent, if it expects to receive more funds. However, NGOs receiving millions in grants and donations often provide very little information about how funds are allocated and spent. Moreover, Haitians can’t demonstrate an ability to provide results without support and funds to even begin. In the future, international NGOs must work with the Haitian government and Haitian NGOs, collaboratively and transparently, in order to best identify problems and solutions in the WASH sector and beyond.

The fact is, more often than not, multiple solutions exist for every problem that arises in the public health sector. The question then becomes: which solution is most appropriate for the context, the most sustainable, the best fit? For example, there are many possible public health approaches to the cholera epidemic that reached Haiti in October of 2010 as a result of unsafe sanitation practiced by United Nations peacekeepers. Numerous actors have attempted to address this epidemic, which is one of the worst outbreak of cholera in recent history, killing more than 9,000 Haitians and causing close to a million to fall ill. Cholera has presented an unimaginable burden on the Haitian people, infecting already poor and sick individuals with a brutal diarrheal disease that is completely preventable. A woman died of cholera right in front of me at our hospital in Belladere, on the border of Haiti and the Dominican Republican in October 2016. 9,000 deaths is a hard statistic to picture, but when a fellow Haitian is dying of cholera before you, what matters isn’t how many cases there have been, or how many people have died. Even one death is far too many.

What is the solution to such a deadly and widespread disease? Especially in a country where a third of the population doesn’t have access to a safe water source, eliminating a water-borne disease poses quite the challenge. Haitians are smart—most of the time, they know they should drink treated water and wash their hands with soap. Even Mika, the smallest girl at the children’s home where I live in Port-au-Prince, often reminds me solemnly of the importance of washing her hands before she eats. The problem is that two thirds of all Haitians live on less than two dollars a day—unemployment, poverty, and hunger are constant challenges for many Haitians, and when people have to choose between feeding their children dinner and buying a bar of soap or a tablet of chlorine to clean their drinking water, food is going to win. The World Food Program reveals that one in three children in Haiti are stunted due to malnutrition, compounded with the fact there is a lack of access to water, further depleting their nutritional intake, ultimately making their situation far worse. Combining contaminated drinking water or poor sanitation practices with existing health issues such as malnutrition, HIV, or TB isn’t just unhealthy—in a country experiencing a cholera outbreak, it’s deadly.

The oral cholera vaccine has been introduced in Haiti as a potential solution to the cholera epidemic. The vaccine, however, has been met with debate regarding its ability to provide widespread protection to the Haitian people. Partners in Health was honored to be among the first to offer support in conducting trials to determine the efficacy of the relatively understudied oral cholera vaccine and its usefulness in epidemic contexts. Another theme of this weeks’ conference is “From Evidence to Action.” Indeed, we have used the evidence gathered in these studies by incredible colleagues, such as Dr. Louise Ivers to propel appropriate action, supporting the Haitian Ministry of Health in a program to administer oral cholera vaccines when it didn’t have the funds to complete the plan on its own. Look at the situation in Yemen at the moment. Almost a million affected and countless lives lost once again. Global discussions remains on where the available stocks of oral cholera vaccines should go. This vaccine, like all vaccines, should go where they are needed and there should be sufficient to go around. It should not be a competition between countries.

However, vaccines aren’t the final answer to eliminating cholera in Haiti. The truth is, no vaccine is 100% effective, some individuals in rural areas don’t have the access or information necessary to ensure that they and their families are vaccinated, and, most importantly, cholera isn’t the only water-borne disease in Haiti. We have a phrase in Creole: Dlo se lavi. Water is life. At the end of the day, clean, safe water is essential. If people drink water that is safely treated to prevent against contaminants and microbes, they are protecting themselves from all kinds of diseases. This is why WASH is the basis for so many other successful programs: we often take it for granted, but without water, nothing else is possible. Effective, accessible WASH infrastructure must be in place in Haiti in order to eliminate cholera and sustain a healthy population.

Partners In Health was founded in Cange, a small town north of Port-au-Prince. For a number of years now, Cange has enjoyed an extensive water system supported by Partners in Health and Clemson University, many of which are present here today including David Vaughn, our teacher, our friend and our partner in saving lives. The Cange water system is fully functioning with chlorine-treated water pumped to eight water fountains that the entire community can access. Despite the high prevalence of cholera in the surrounding areas, no cases of cholera were reported in Cange, which is located in the Central Plateau where cholera originated and has the highest rates of cholera prevalence. Cange remains almost cholera free, where cases reported are from people who have traveled from other parts of the region. Although we can’t officially attribute the lack of cholera in Cange to the water system, the fact that residents have free access to treated water is certainly a positive factor in the overall health of the community.

In fact, Partners in Health has worked extensively with partner NGOs such as Operation Blessing International also here with us today to provide clean, safe water to Haitians throughout the country. Water is connected to all aspects of health, of course, and so we have been contributing to the WASH sector in Haiti where we work since the beginning of the organization. Focusing on WASH in schools was important to us, as schools are in many ways the center of a child’s life. Growing up many years ago in Port-Salut, I was lucky enough to attend a parochial school with a toilet. My family had a toilet and water piped into our home as well. However, many children in Haiti, especially in rural areas, aren’t so lucky. We are proud to say that as a result of WASH in Schools programs completed between 2014 and 2017 in partnership with USAID and UNICEF, Partners in Health offered WASH support to 31 schools, reaching a total of 10,000 students. Among other activities, these initiatives included building toilets and handwashing stations, working with teachers and students on safe hygiene practices, establishing water points, and creating waste pits. 1,000 families were supported in building their own toilets, which is important because within all programs, Partners in Health focuses on supporting Haitians to find solutions that they understand, support, and create for themselves.

As you all know, however, WASH is about much more than just water. Partners in Health also focuses on other elements of WASH, including Community-Led Total Sanitation, or CLTS. CLTS programs focus on community-driven efforts to rid areas of open defecation, which is the cause of many water-borne illnesses in rural areas. CLTS aims to promote a change of collective norms at the group level and personal habits at the individual level. Communities that have been certified open-defecation free are able to take control of their health without waiting for the UN or anyone else to arrive with assistance.

Thankfully, cholera cases have been decreasing in frequency since the initial outbreak began in 2010. In 2011, Partners in Health saw almost 70,000 cases of cholera in our public clinics and hospitals. 268 of our patients died of cholera that year. Numbers have, thankfully, decreased since then: in 2016, we saw less than 9,000 cases of cholera, with 24 deaths. One death due to unclean water or improper sanitation and hygiene is too many, and we will continue to strive for a Haiti in which everyone has access to safe, accessible WASH. Partners in Health and GHIESKO the only NGO’s in Haiti that opened its cholera treatment centers since 2010, and has remained opened. Even when there was no funding for cholera, Partners in Health stayed.

Partners in Health’s strategy is one of accompaniment, of human rights, and of a holistic, comprehensive approach to health. Accompaniment is a term we use frequently because it’s central to our presence in Haiti. We are not in the business of providing services and leaving. Instead, we prioritize solutions that work for the community and with the community, that allow Haitians to have autonomy over their own health, and that strengthen national systems and capacity. CLTS is a good example of a program that empowers individuals to create their own health solutions, but Partners in Health strives to act as an accompanateur in all aspects of health care and in every project that we start.

We also take a human-rights based approach: based on international treaties, we believe that it is a recognized human right to be able to enjoy clean water. Elevating water to the level of a human right, is equal to other rights such as the rights to life and liberty, highlights just how fundamental water is to survival, and how important it is to fight for this right to be realized for all people.

Finally, by approaching health comprehensively, we acknowledge that without clean water, a child can’t learn—but without teachers and textbooks, he/she can’t learn either. Health is linked to education, to gender equality, to housing and safety. We will do whatever it takes to improve the lives of those with the least access to basic services. We are a health organization, but we don’t just focus on health—we’re looking to help Haitians every step of the way.

The outlook of Haiti is in many ways tied to the future of health. In 2016, Ban Ki-moon, then-Secretary General of the United Nations, issued a formal apology on behalf of the UN for bringing cholera to the island of Hispaniola. His apology included a two-track plan, to be carried out by the UN in the coming years in order to mitigate some of the negative impacts of cholera on the Haitian people.

Although Ban Ki-Moon’s plan is a good one, I worry that the UN’s words won’t ultimately match their actions. Already, I have seen suggestions that cholera survivors will be left out of future programming. Haitians need to see the UN responding to a mistake that introduced a deadly disease to an already struggling country. Memorials could be held in Mirebalais, where the first cases were located. Some kind of collective support could be offered to towns who were greatly affected, such as support to schools or community centers. An apology is well received but not enough. Survivors deserve direct support. Already, the Haitian government is cutting health budgets—it is more important now than ever to build water systems and health infrastructure.

In Creole, we have a phrase: Wòch nan dlo pa konnen doulè wòch nan soley, the rocks in the water don’t know the suffering of the rocks in the sun. Donors, international NGOs, and foreign governments will never be able to fully understand what it is like to be a Haitian. This is why the principles of human rights and accompaniment are so central to Partners In Health’s work in Haiti and around the world. By focusing on water and other aspects of health as human rights, we solidify their importance. The ability of all people to live healthy lives must be respected not just as a desired outcome but as a fundamental right, regardless of citizenship or place of birth. Partners In Health seeks not to blindly provide services or fix problems, but rather to identify the root cause of suffering and stand in solidarity with local communities to find empowering solutions together. And, as a room full of WASH experts certainly knows, one of the first steps along that journey is water.

After all, dlo se lavi—water is life.

Thank you for your time.