For most Haitians, when health care is available at all, it all too often treats the immediate problem only. Given the conditions under which the vast majority of Haitians live - dire poverty, malnourishment and lack of access to water or sanitation - the next illness or physical challenge is an ever-present threat.
Poor health is not simply a result of biology, but a direct result of national and international policies and programs which foster poverty and inequality. Improving health care requires addressing the social causes of poor health. Known as the social determinants of health, these are the economic, political and social conditions in which people are born, live and work.
Advocacy for a more just and equitable political economy is required for Haitians' health to prosper. So, too, is health care which addresses structural impediments to well-being. The Association for the Promotion of the Health of the Family (APROSIFA by its French acronym) is that type of health care. The multi-faceted program in the extremely low-income Port-au-Prince neighborhood of Carrefour Feuilles both offers a clinic and addresses social determinants. APROSIFA founder and technical adviser Roseanne August tells about the work:
There's no social security system in Haiti. When you intervene in the health of a neighborhood, you have to identify the social programs that underlie the state of health.
Health is not just medical care. Health depends on many factors. It's about people becoming responsible actors, questioning what's happening in their neighborhood, improving the community. But health is something larger still. Health is the right of people to eat, to have a place to live, to love - yes, love, because love is part of people's physical and emotional equilibrium - and to have a clean, healthy environment to live in.
We built APROSIFA with the support of Paul Farmer from Partners in Health in '93. From the beginning we gave priority to those who were most in need. We focused on women, youth and children. We opened the clinic and we've accompanied them ever since. We refuse to become a big organization with a lot of money and a bureaucracy, which can intimidate people who are very vulnerable.
We struggle to provide services that respect the dignity of the people. During 17 years, more than 300,000 people have passed through APROSIFA. We've closely accompanied about 600 to 700 kids from the cradle on. We see about 200 people each day in the clinic. We have 40 staff, some in the clinic and some doing outreach in the region. We have doctors, nurses, nurse-midwife, auxiliary nurses, lab technicians, social workers, health outreach workers and administrators.
In the beginning, we operated in the classic public health schema. You have a clinic, you provide contraception, you do vaccinations, you teach protection against AIDS, etc. But we've realized that's not what health is. We had to reflect with the people to better understand what health really means. They've taught us to question the dominant model of health provision.
Our clinic is always open, but our work of social programs on the ground, we reevaluate and renew that every two years to reflect developments in the neighborhood. For example, there's been a lot of violence around here in the past couple of years, so we've worked hard with youth for violence prevention. There aren't any recreation centers in the area and the kids have nothing to do. We started an art program for them so they can transform themselves into responsible actors.
People say, "You're a clinic. Why are you involved in painting, sculpture, photography, videography?" These people in conventional public health, they don't know the relationship between painting or sculpture and health. They don't know that when someone has a paintbrush in his hands, when he's involved in something meaningful, he can free his mental state from being constantly burdened with problems. Plus he has can make some money and change the conditions of his life. We've seen good results from the youth we work with. We're proud of them.
It's not just to teach the kids and then send them away; we're here to help them reflect on social issues. We have a crafts program for kids with recycled garbage, for example. The kids think, "I shouldn't just throw my water sack or empty spaghetti bag on the street. In fact, I could reuse it, sell what I make and help out my mother."
When babies and little children come into the clinic, we weigh them. If they're underweight, we put them into our program for six months. We embrace that child and help their mother out. They get enriched milk two or three times per day and a bowl of hot food in the afternoon, like soup enriched with peanut butter or porridge with enriched flour. We normally take between 25 to 35 malnourished children, from birth to three years. Since the earthquake, given the precariousness of the lives of women who've lost their homes, we're up to 49 children and we want to go up to 75. As soon as a child is better, we let him or her go and take in another.
We do literacy classes with the mothers, though we've had to pause since the earthquake. We also do workshops with them about sexual and reproductive rights, violence against women and all issues related to women's health. We give them a little financial support so they can run a little business, but we don't do micro-credit because we don't believe in it.
But we're just a neighborhood association. We are neither an NGO nor the state. We work a lot with the Ministry of Health on tuberculosis vaccinations, for example, but we're not the ones who are going to change the social conditions of people's lives. We don't delude ourselves.
What we do, we do with very little money. We can do it thanks to the support of our partners: Christian Aid, Oxfam Great Britain, ICCO, Partners in Health. Some agencies can't understand our approach because they have a rigid schema in their head of what public health is supposed to be. They see us as rebels because we're always reminding them that the reality isn't how they understand it, though we always work it out.
I'd like to tell the international agencies that they have to work in alliance with the state. And that, after the earthquake, it's important for them to connect with organizations whose philosophies correspond to the needs of the population. It makes me suffer to see how much money is wasted, going to programs that don't do any good for the people. The agencies should learn from these small organizations that have developed different models for working with people. APROSIFA isn't like any other group, but there are other good models that the international agencies can use as a school.