# Lentis/Water Supply, Sanitation, and Public Health in Haiti
## Introduction

Haiti hosts a population of 10.4 million people, over 80% of which live in poverty. It is the poorest country in the Americas, with a gross domestic product (GDP) per capita of 846 USD in 2014. Despite international aid efforts, Haiti has had the lowest rates of access to improved water and sanitation infrastructure in the western hemisphere, ranking 163 out of 188 countries in the United Nations Human Development Index. Historically, foreign aid has primarily focused on providing immediate relief to the population instead of infrastructure development due to corruption and efficiency concerns in the Haitian government.

## History of Water Supply, Sanitation, and Public Health
### Political Impact on Water Supply and Sanitation Methods

Successful national water supply and sanitation systems are reliant on organized governments that are capable of providing services to their citizens. Haiti has a history of political turmoil and governmental fragmentation that has complicated the creation of such a program. Various institutions have been formed to manage water supply, but with continuously shifting political power the institutions have been inefficient and transient. In 1964, president François Duvalier created the Centrale Autonome Metropolitaine d’Eau Potable (CAMEP) to provide water supply exclusively to Port-au-Prince, the Haitian capital. This was replaced in the 1970s when his son, Jean-Claude Duvalier rose to power and formed Service National d’Eau Potable (SNEP) to provide water supply to urban zones. These programs both neglected rural areas and left residents without improved sources of water. During this time period, Haiti represents a case in which corrupt governments are unable to provide successful programs to supply water to their citizens.
Haiti's government transitioned to a democracy in 1986, and in 2009 the Haitian parliament created the regulatory body National Directorate for Potable Water and Sanitation (DINEPA) to implement water supply and sanitation reform, focusing primarily on rural zones. It was allotted a budget of 300 million USD and developed a three-year plan of action for 2009-2011. This marked promise that with new government reform, Haiti would finally be able to provide the population with clean drinking water and access to hygienic sanitation methods.

### 2010 Earthquake

Catastrophic natural disasters have the capability to destroy infrastructure on which a nation was previously reliant, creating a stall period during which new, often crude, methods have to be developed to replace that infrastructure. A good example of technological renovation following natural disaster is the response to nuclear energy following the 2011 Japan earthquake and tsunami.
On January 12, 2010, Haiti was struck by a 7.0 magnitude earthquake. 230,000 people were killed and over 13 billion USD in damages was done. Two million people were herded into internally displaced persons camps. Sanitation was compromised as sewage facilities were underdeveloped or non-existent and open defecation was common. Following the earthquake, 69% of the population had access to a clean water supply, as water was polluted with debris and human or animal waste, and 17% had access to improved sanitation methods such as latrines. This disaster sparked the need for makeshift technologies and international aid to provide water supply and sanitation.

### Cholera Outbreak

In October 2010, nine months after the initial earthquake, a cholera outbreak began in the rural center department of Haiti, about 100 kilometers north of Port-au-Prince. By March 2011, 4,672 Haitians were dead, with thousands more hospitalized. Due to limited access to clean water and infrastructure, cholera had spread to all ten of Haiti’s provinces within ten weeks of the initial outbreak.
In November 2012, Haiti’s Ministry of Public Health and Population released a report titled, “The National Plan for the Elimination of Cholera in Haiti”, which detailed the government’s plan to eliminate cholera by 2022. Since the enactment of this plan, monthly cases of cholera have dropped from 29,000 in November 2012 to 1,240 in November 2014.

## International Response
### Social Media Response

In natural disaster response, social media supports information exchange and ad-hoc network formation. Following a disaster, individuals and agencies share information under different contexts to find common ground. From this, relief efforts and awareness programs are synthesized and implemented.
Following the 2010 earthquake in Haiti, social media informed the public of current events and relief efforts. Aside from Twitter and Facebook, Microsoft SharePoint and the government MediaWiki platform (Intelink) were used for inter-staff communication and United States agency collaboration, respectively. Twitter connected users with common causes, through hashtags and retweets, and allowed users to voice their opinions and partake in self-promotion.
The American Red Cross created an interactive donation program where users could text to donate money to the relief effort. This contributed to the 488 million USD the American Red Cross has raised towards Haiti relief. This success can be attributed to Jim Manis and Jenifer Snyder of the Mobile Giving Foundation. They negotiated with wireless companies to ensure that 100% of donations went directly to the charity. Manis, the founder of the Mobile Giving Foundation, used the term “micro-donations” with wireless companies to make the program seem manageable and feasible. Donating through text has been widely successful, but there is question as to how the money is actually allocated or used in Haiti.

### Non-governmental Organizations (NGOs)DD-WRT/Features

NGOs in Haiti have dedicated significant resources towards humanitarian aid, with over 550 million USD coming from the United States alone since the 2010 earthquake. Prior to the earthquake, there were estimated to have been between 3,000 and 10,000 NGOs operating in Haiti between 1970 and 2010, the second highest number of NGOs per capita in the world. Due to concerns of corruption within Haiti's government, foreign donors often bypass the government and direct most or all financial and material assistance through NGOs. The United States Agency for International Development (USAID), directed all of the 300 million USD spent in Haiti from 2007-2008 to NGOs.
Following the 2010 earthquake, NGO presence in Haiti drastically increased. However, the large influx of aid workers and money highlighted issues concerning NGO accountability and regulation. Because many NGO organizations rely almost completely on foreign contractors, it is difficult to track where money is being spent and which projects the funding is being used for. Additionally, these projects are not sustainable over the long term because NGO-implemented projects are generally not officially affiliated with the Haitian government.

## Haitian Response
### Point-of-Use Technology

Haiti has been reliant on point-of-use (POU) water treatment, rather than a central water system, due to slow economic growth and political instability. Following the earthquake, many underground pipes ruptured followed by a cholera outbreak. Nonprofits tried installing large scale water systems but failed due to unreliable international aid..
Successful POU technology relies on social acceptance from its users. Aquatabs are accepted because they treat five gallons of water, the same volume as a “bouquite” commonly used by Haitians. Haitians also associate Aquatabs with higher social status, saying “Aquatabs are for gentlemen” and comparing the water to Culligan, commonly described as “the water that rich people drink”. Barriers towards successful POU treatment include cost and unfamiliarity with the technology. For example, many Haitians believe that supernatural powers control nature and therefore their water supply. They have trouble accepting POU technologies because they believe little can be done to better their situation.
Common POU technologies include chlorination, ceramic filtration, slow sand filtration, and disinfectant powder. Oxfam America began installing chlorine boxes as a method of water treatment in 2012. As of 2015, International Action will begin to install permanent Chlorine Distribution Systems (CDS). Chlorination is inexpensive and effective. This established system could expand and develop over time.

### Domestic Welfare

Following the earthquake, new water supply systems impacted different social sectors of Haiti, highlighting the influence of natural disasters on unorganized social groups. Women and children were primarily responsible for collecting water from polluted rivers and streams, balancing and transporting buckets of water on their heads. This limited women's independence by keeping them from partaking in commercial activities and prevented children from attending school.
DINEPA is currently trying to make water collection more professional. International donors contribute water supply systems, such as spigots drawing water from springs, but rarely maintain them as it is not economically feasible: the cost for operating a water supply system for ten years is three times that of installing it. As a result, local communities form water committees and maintain the water supply systems, which often overburdens the operators. For rural residents, there is little to no economic value in operating the equipment. Marc Antoine Castel, a rural water operator, manages his town's water supply system every day of the week and often on weekends and holidays as well. However, he says he does it out of love for his community and receives no pay for it, instead making his wage as a high school teacher and lawyer.

### Mental Health

Mental health directly affects a nation's morale which can further or diminish societal progress. Psychiatric facilities in Haiti are lacking in resources and funding. The 2010 earthquake highlighted the absence of any national mental health planː Haiti has not received promised foreign aid or allocated funds appropriately towards improving citizens' mental health.
Partners in Health (PIH) nonprofit sister program in Haiti, Zanmi Lasante, is working to create a decentralized model of mental health care. Zanmi Lasante has implemented mobile clinics in an attempt to break presumed barriers of mental health, such as stigma, literacy, and cost, and to educate others about mental health.
WomenStrong International (WSI), a consortium of nonprofits working to empower women, openly supports Haiti’s women’s health outreach program, Haiti Outreach - powje-espwa (H.O.P.E.). This partnership aims to unite all H.O.P.E. programs directed towards women under one program called S.E.E. Fanm.
Restavéc has been detrimental towards mental health in Haiti and is referred to as the “modern-day slavery”. According to Legha and Solages, the “Restavéc phenomenon” describes children who are overworked, abused, and malnourished. The Jean R. Cadet Restavéc Organiztion works to end this practice and end child slavery, featuring videos from celebrities and endorsers supporting their work. All of these programs have been effective in improving mental health within Haiti as the nation continues to rebuild and develop.

## Conclusions

Haiti, and other developing countries, can provide valuable lessons to the international community in how to effectively provide foreign aid. Failing to account for a country's unique set of governmental, societal, and economic circumstances can prevent real progress from occurring despite increasing amounts of donations made possible by new technologies. While social media connects the developed and developing worlds and provides an outlet that facilitates distribution of aid and increases public involvement, it is unclear how effective a single person’s contribution is to the relief effort or what incentivizes certain social groups to contribute.
The aftermath of the earthquake and new technologies for water supply and health shook Haiti’s social structure, illustrating how natural disasters can exacerbate mental health, gender, and socioeconomic class divisions. As a result, these social barriers can hinder the effectiveness of relief efforts. While this case is specific to the social classes in Haiti, a country that has struggled with political turmoil and poverty, it would be interesting to see how a country with concrete access to water supply infrastructure and provisions for health care would respond to a similar natural disaster.

## References

* 1 2 The World Bank. (2014). Clean Water, Improved Sanitation, Better Health. Washington, D.C. http://www.onu-haiti.org/wp-content/uploads/2014/12/Clean-Water-Improved-Sanitation-Better-Health.pdf.
* ↑ The World Bank. (2015). Haiti: Overview. http://www.worldbank.org/en/country/haiti/overview.
* ↑ UNDP. (2015). United Nations Development Programme. Human Development Reports [Data file]. http://hdr.undp.org/en/data.
* ↑ Bliss, K. E., & Fisher, M. (2013). Water and Sanitation in the Time of Cholera: Sustaining Progress on Water, Sanitation, and Health in Haiti. Center for Strategic & International Studies. http://csis.org/files/publication/130905_Bliss_WaterSanitationCholera_WEB.pdf.
* 1 2 3 Gelting, R., Bliss, K., Patrick, M., Lockhart, G., & Handzel, T. (2013). Water, Sanitation and Hygiene in Haiti: Past, Present, and Future. The American Journal of Tropical Medicine and Hygiene, 89(4), 665-670. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3795096/.
* ↑ Center for Global Health. (2013). Progress Toward Rebuilding Haiti’s Health System. http://www.cdc.gov/globalhealth/healthprotection/errb/pdf/progresstowardrebuildinghaitishealthsystem.pdf.
* ↑ UN. (2014). Final Report of the Independent Panel of Experts on the Cholera Outbreak in Haiti. https://www.un.org/News/dh/infocus/haiti/UN-cholera-report-final.pdf
* ↑ UN. (2014). United Nations. Haiti Cholera Response. http://www.un.org/News/dh/infocus/haiti/Cholera_UN_Factsheet_January_2015.pdf
* ↑ Basu, M. (2010, December 31). Cholera death toll in Haiti rises to more than 3,000. http://edition.cnn.com/2010/WORLD/americas/12/31/haiti.cholera/index.html?hpt=T2
* 1 2 Yates, D., & Paquette, S. (2011). Emergency knowledge management and social media technologies: A case study of the 2010 Haitian earthquake. International Journal of Information Management, 31(1), 6-13. Web of Science.
* ↑ Smith, B. G. (2010). Socially distributing public relations: Twitter, haiti, and interactivity in social media. Public Relations Review, 36(4), 329-335. Web of Science.
* ↑ Haiti Assistance Program | Red Cross | Haiti Aid. (2015). http://www.redcross.org/what-we-do/international-services/haiti-assistance-program.
* ↑ Straus, T. (2010). Five-Digit Giving (SSIR). Stanford Social Innovation Review. http://ssir.org/articles/entry/five-digit_giving.
* ↑ Interview with Jim Manis of the MGF – Mobile Commons. (2008, August 29). https://www.mobilecommons.com/blog/2008/08/interview-with-jim-manis-of-the-mgf/.
* ↑ Patrick, J. (2011). Evaluation Insights: Haiti Earthquake Response. Organisation for Economic Co-operation and Development. http://www.oecd.org/countries/haiti/50313700.pdf
* ↑ Kristoff, M., Panarelli, L. (2010). Haiti: A Republic of NGOs?. United States Institute of Peace. http://www.usip.org/sites/default/files/PB%2023%20Haiti%20a%20Republic%20of%20NGOs.pdf
* ↑ DesRoches, R., Comerio, M., Mooney, W. (2011). Overview of the 2010 Haiti Earthquake. United States Geological Survey. http://escweb.wr.usgs.gov/share/mooney/142.pdf
* ↑ Varghese, A. (2002, June 1). Point-of-use water treatment systems in rural Haiti: Human health and water quality impact assessment. Massachusetts Institute of Technology. http://web.mit.edu/watsan/Docs/Student%20Theses/Haiti/Varghese2002.pdf.
* 1 2 Know, R. (2012, May 16). Water in the time of cholera: Haiti’s most urgent health problem. NPR. http://www.npr.org/sections/health-shots/2012/04/13/150302830/water-in-the-time-of-cholera-haitis-most-urgent-health-problem.
* 1 2 3 Global development alliance: Safe drinking water alliance. (2008, December). United States Agency for International Development. http://pdf.usaid.gov/pdf_docs/Pdacn883.pdf.
* ↑ Gift of water: Filtration & chlorination system. (n.d.). Gift of Water. http://www.giftofwater.org/the-solutions.htm.
* ↑ The cholorine distribution system (CDS) project. (2011). International Action. http://www.haitiwater.org/our-work/chlorine-distribution-system-cds-project.
* ↑ Dupuy, M. A., Espaillat, L. R., Fu, R., & Wang, J. C. (2011). Rainwater Harvesting in Matènwa, Haiti: An Interactive Qualifying Project (Undergraduate thesis). Worcester Polytechnic Institute. https://www.wpi.edu/Pubs/E-project/Available/E-project-053111-152653/unrestricted/Haiti_Water_IQP.pdf.
* ↑ Hutton, G., & Bartram, J. (2008). Global costs of attaining the Millennium Development Goal for water supply and sanitation. World Health Organization. http://www.who.int/bulletin/volumes/86/1/07-046045/en/.
* ↑ Brown, D. (2012). In rural Haiti, looking for a way to make clean water sustainable. The Washington Post. https://www.washingtonpost.com/national/health-science/in-rural-haiti-looking-for-a-way-to-make-clean-water-sustainable/2012/10/09/33582536-b4e0-11e1-9e4c-5a6a137d65e1_story.html.
* 1 2 3 Legha, R. & Solages, M. Child and Adolescent Psychiatric Clinics of North America, 2015-10-01, Volume 24, Issue 4, Pages 731-749, Copyright © 2015 Elsevier Inc. Web of Science.
* ↑ New mental health program launches in Haiti. (2012, November 30). Partners in Health. http://www.pih.org/blog/new-mental-health-program-launches-in-haiti.
* ↑ 5 Zanmi Lasante Grelotti et al Mental Health Mobile Clinics. (n.d.). Rebâti Santé Mentale. http://rebatisantementale.org/publications/5-zanmi-lasante-grelotti-et-al-mental-health-mobile-clinics/.
* ↑ Haiti Outreach – pwoje espwa (H.O.P.E.) – S.E.E. – Fanm. (2015). https://www.womenstrong.org/projects/haiti-outreach-pwoje-espwa-hope-see-fanm.
* ↑ http://www.hopehaiti.org/WHATWEDO/HEALTH/WomensHealth/tabid/161/Default.aspx
* ↑ In the news and media. (n.d.). The Jean R. Cadet Restavek Organization. www.jeanrcadet.org.