Haiti has at least 7,743 confirmed cases of Covid-19 and at least 187 deaths, according to the World Health Organization. But the relatively low numbers might not tell the full story, warn health care workers and others working to alleviate the outbreak in the Caribbean nation.

“It’s really hard to say what is the state of Covid-19 in Haiti right now. Many people don’t believe in the pandemic in Haiti. People are staying home and self-treating. They’re not going to the hospital,” said Margarett Lubin, country director of Haiti for CORE, a nonprofit started by Sean Penn after the 2010 earthquake in Haiti. She, and colleague Dr. Floris Nesi, added that a lack of testing has also contributed to the opaque situation.

Commingled with these issues is widespread mistrust amongst the population towards the government and public health authorities, who often must battle misinformation, which can further stigmatize patients seeking care.

Despite ongoing outreach campaigns to counter these conspiracy theories with scientifically-supported public health policies, progress has been meager, according to Nesi.

“For the most part people are not listening,” he said, which Lubin said is also reflected in the crowded Port-Au-Prince streets as well as the open markets, offices, including government offices, and international airport. Nesi said many Haitians “Don’t believe in the care they provide in hospital,” and that they prefer to treat themselves using traditional medicines, including teas made from armoise (mugwort) and other local plants. He said that people have tended to only visit hospitals only in the late stages of the disease when positive outcomes are far less likely. Lubin said that for many, staying at home or adhering to public health recommendations is difficult due to their need to continuing earning income.

But even if people change their perspectives, and seek care in hospitals and clinics, it is unlikely that the nation has the capacity to treat them, Nesi said.

“The big challenge is the health system is not ready for this virus. We have only 1,120 hospital beds,” Nesi said. A 2019 report in PLoS ONE found that the country only has 124 ICU beds.

Lubin also pointed out that a Covid-19 response also has to be integrated into a healthcare system that must continue to treat those with malnourishment, diabetes, hypertension, and other chronic conditions. Nesi said that many people are forced to travel far distances in order to access care, leading him to believe that a proper solution must be a joint program with several ministries, including those responsible for transportation, education, health, agriculture, and food.

Despite the many unknowns, Lubin and Nesi feel comfortable declaring that there is currently no surge in Haiti, even as testing rates remain relatively low, thanks to more traditional modes of communication.

“News travels so fast here, in cholera you knew exactly what was happening, also from the media, and because people were dropping dead. We’re not seeing any of that and we haven’t heard that either,” Lubin said. “There is no way the government would be able to hide a real outbreak,” she said, though cautioned that one could very well be impending, given the pervasive lack of adherence to social distancing and other public health directives.

Learning From Cholera

CORE and other NGOs have been relying on lessons from their response to cholera and the 2010 earthquake in order to inform their operations and communication strategies for this current outbreak. The Covid-19 pandemic in Haiti, the second-most populous country in the Caribbean with about 11 million people, comes after a cholera epidemic that killed at least 9,200 Haitians and infected at least 820,000 people, according to the Pan-American Health Organization.

Starting in 2010, the last case was identified in January 2019. Beyond the sheer scale of destruction, that experience also had a lasting impact among the population. Despite substantial evidence to the contrary from as early as 2011, the UN officially denied responsibility for years, before finally admitting their role in 2016, as the outbreak was shown to have originated from UN peacekeepers from Nepal.

“The people telling them to wash their hands were infecting them,” said Mark Schuller, an anthropology professor at the Northern Illinois University and president of the Haitian Studies Association. “It struck as hypocritical and infantilizing,” he said, noting that the years of denials “cost the UN any kind of legitimacy amongst most professionals in Haiti.”

That legacy is something CORE is having to deal with now. The NGO has sought to do so, in part, by finding the most influential members of a given area. “When you go into a community and you try to collaborate and engage with leaders to participate, don’t just look for local officials, but really look into those people that the community looks to up and listens to and try to integrate them into the program,” Lubin said.

When she and her team first started their outreach programs, Lubin said there was widespread resistance to establishing Covid-19 clinics in some communities due to unfounded fears that such clinics would help spread the disease. It was only after CORE mobilized local volunteers to engage locals and explain the situation that leaders changed their minds.

Other, more subtle strategies emerged only after trial and error during this pandemic. When CORE members visited the most vulnerable neighborhoods in Port-Au-Prince and more remote areas in the western part of the county to hand out masks, many did not want to accept them, since the masks being handed out were different than the masks CORE staffers and volunteers were wearing.

A Legacy of Mistrust

Schuller said that the origin of mistrust in Haitian society towards their government, the UN, the U.S., Europe, and other actors is deep-seated and based on centuries of adverse, and even punitive, policies.

“Haiti has been subjugated because of its role as a foil to slavery. It’s unbroken. Haiti was invaded 26 times,” he said. Since the U.S. left in 1934, policies set in Washington and Brussels have also propped up unpopular Haitian regimes, which Schuller said has created “two layers of distrust for specific foreign injustices.” Prior to the Covid-19 conspiracy theories, this mistrust was also exemplified by widespread protests last summer and fall as well as earlier this year over, inter alia, $2 billion in missing public funds for large scale infrastructure projects, government spending decisions, and working conditions for police.

“People are very suspicious of the government and you have to collaborate with the government to do this work, so people see you as choosing sides. We received masks from the Ministry of Health and people recognized masks as being from the government and thought they were contaminated,” Lubin said. To allay such fears, she mandated that CORE personnel would wear the government-provided masks during distribution, in order to help build trust.

Public health challenges in Haiti have been more fundamental. As late as June, in some western parts of Haiti, people had not heard of Covid-19, Lubin said.

Underlying issues of poverty on the island are also impairing the ability of healthcare workers to respond in this pandemic and to chronic health issues in general. As is often the case at community health centers in the U.S., Nesi gave the example of instances when he prescribes patients medicines that have to be taken with food, and patients have responded that they are food insecure, before asking if he could prescribe another drug that does not require food.

Even as these issues persist, there are some bright spots.

“They say it’s a disease from foreign people who are trying to kill them, or they say don’t believe in it, but many do something underground, like with cholera. They start washing their hands more,” Lubin said. “But it was only when they saw people die in the streets during the cholera outbreak that they really started to follow recommendations.”

Since the nature of Covid-19 is different, such visual clues might indicate a situation that is already out of hand.

“We are very scared about the situation in 2 to 3 months. We don’t have collective immunity… It might come, I hope it doesn’t,” Nesi said.

Since 2010, Direct Relief has delivered $348 million in medicines and medical supplies to Haiti in support of 224 healthcare centers. Support has been built around several disasters including the 2010 earthquake, cholera outbreak, Hurricane Matthew, and ongoing public health initiatives.  Direct Relief’s year-to-date support to Haitian healthcare centers is valued at $20.8 million and has supported 23 health centers. Direct Relief’s Covid-19 response in Haiti has included the delivery of oxygen concentrators, Emergency Medical Packs, Covid-19 ICU kits, as well as financial support to groups providing medical care in the country.