Haiti’s Disease of Unpreparedness: Why The UN’s Political Declaration on Antimicrobial Resistance Isn’t Enough
The 79th session of the United Nations General Assembly (UNGA) drew all eyes toward the global health community as the Quadripartite partnership led by the World Health Organization, Food and Agriculture Organization (FAO), the World Organization for Animal Health (WOAH), and the United Nations Environment Programme (UNEP) prepared for the second high-level discussion on Antimicrobial Resistance (AMR). This culminated in a high-level political declaration urging governments to take greater action in addressing AMR in their countries. Since the declaration, criticism has continued to grow as global health thought leaders argue that the political declaration does not offer a realistic implementation plan for low-middle-income countries (LMICs) experiencing severe economic challenges and ongoing humanitarian conflict, as in the case of Haiti.
AMR in Haiti contributed to over 10,000 deaths in 2019 alone (Figure 1), superseding deaths related to respiratory diseases, HIV/AIDS, maternal deaths, and other non-communicable diseases, ultimately ranking Haiti as having one of the highest age-standardized mortality rates attributed to AMR in the Caribbean. AMR happens when bacteria or fungi are no longer responsive to antibiotics causing significant challenges in treating diseases. This is projected to cause significant challenges and worsening health outcomes in LMICs.
Figure 1: AMR in context with other causes of death in 2019 in Haiti.
Source: healthdata.org/sites/default/files/2023-09/Haiti.pdf
Despite the increasing political momentum to combat AMR, the grim reality on the ground in Haiti paints a different picture. The country grapples with significant health infrastructure challenges (Figure 2) and severely underfunded national health programs undermining international leaders' ambitious health security goals. As infectious diseases continue to proliferate in Haiti, the most pressing threat to Haiti’s global health security that looms larger than ever is depicted in itself as the disease of unpreparedness.
Figure 2: Functional Status of Health Infrastructure in Haiti, 2024. (Green=Functioning; Orange= Partially Functioning; Red=Not Functioning)
Source: Pan American Health Organization / World Health Organization Haiti Country Office. 27 September 2024. Port-au-Prince; 2024.
Political & Structural Challenges Impeding Global Health Security in Haiti
The Global Health Security Index (GHSI) evaluates a country’s level of health security preparedness across areas of prevention, detection, reporting, rapid response, health system strength, compliance with international norms, and overall risk environment. Haiti’s low ranking of 130/195 on the GHSI indicates significant gaps in Haiti’s preparedness and ability to respond to growing health crises and pandemics. Haiti’s weakest subscore on the GHSI (indicator 5.3-International Commitments) reflects the country’s inability to uphold global norms around global health security and facilitate exchanges of technical expertise. This represents a gap between high-level decision-making for health security and local implementation in Haiti, hindering effective responses to public health crises.
In May 2024, the World Health Assembly (WHA) convened to adopt amendments to the International Health Regulations (IHR), a legally binding framework established by the WHO to help countries manage public health risks that have the potential to cross borders and impact global health security. The amendments aim to enhance the speed and clarity of health information sharing, ensure equitable access to essential health products, and strengthen global health security while respecting national sovereignty. While remarks by Haiti’s Ambassador to the United Nations, His Excellency Justin Viard, highlighted the need for equitable health systems and international collaboration, key levers such as increased political will, strategic engagement, and visionary leadership at national level continue to impede building Haiti’s health security resiliency and ensuring preparedness.
Despite developing a robust National Action Plan (NAPs) to combat AMR, Haiti still faces an uphill battle in implementing these ambitious global objectives within actionable national strategies and plans. Additionally, data availability and utilization remain a challenge for Haiti, failing to report over four years of data in tracking AMR progress. The country has inconsistently reported on the Tracking AMR Country Self-Assessment Survey (TrACSS), a self-reporting tool developed by the WHO to monitor a country's progress on its National Action Plan implementation. With limited financial support and resources, the targets outlined in the NAPs remain unattainable.
The State Party Self-Assessment Report (SPAR)—is a self-assessment tool developed by the World Health Organization (WHO) that allows a country to self-measure its compliance with the International Health Regulations (IHR). The SPAR is intended to be complemented by a Joint External Evaluation (JEE), a multisectoral assessment evaluating a country's ability to respond to public health threats. While the SPAR is intended to guide IHR implementation and capacity-building, its scoring system has been widely criticized as the “invisible metric” as it may inadvertently reinforce existing inequities by failing to account for the realities faced by lower-income countries. The SPAR fails to consider a country's dependence on external aid and factors in technical health system capacities rather than external issues without adequately considering structural challenges like political instability and informal health networks that are unique to low- and middle-income countries (LMICs).
Haiti’s aggregate low SPAR scoring of 40/100 reflets low performing core competencies in areas such as health service provision and points of entry (e.g., airports, seaports). Countries like Haiti, which rely heavily on external aid and international support for health security, are often scored the same way as high-income countries with vastly different levels of domestic resources and governance structures. The unfair comparison between low-scoring LMICs and high-scoring high-income nations does not allow countries like Haiti to demonstrate its resilience in public health crises. As a result donors become more hesitant in supporting health security initiatives with low scoring countries. This discrepancy highlights the need for a more equitable and context-sensitive approach to health security assessments, one that adjusts for resource disparities, acknowledges informal health system structures, and prioritizes capacity-building over rigid compliance scoring.
AMR: A Silent Pandemic? Or Neglect by the Global Health Community?
The controversial narrative that AMR is recognized as a “silent pandemic” reveals a global response to AMR and health emergencies rooted in structural racism and nuanced inequities. Low-income countries often bear the brunt of AMR’s consequences, reflecting a broader pattern of neglect in the global health sector. In reality, Haiti’s AMR crisis has been nothing short of silent but has fallen on the death ears of the international community. Since 2014, Haiti’s health ministers have been sounding the alarm on growing drug-resistant epidemics like Tuberculosis (TB) and Cholera. An estimated 2.9% of new TB cases and 13% of previously treated cases in Haiti are multidrug-resistant (MDR-TB). Although attention has been given to the recent resurgence of Cholera, we must not forget the blind eye that was turned on Haitian health officials in 2010 who first alerted on the drug-resistant cholera outbreak strain. Haiti’s cultural norms to self-medicate due to the lack of access to and affordability of formal health facility treatment coupled with the parallel market for contraband pharmaceuticals exacerbates the problem. Antibiotics are frequently sold illegally by street vendors and in unlicensed pharmacies without prescriptions (Figure 3). Estimates indicate that up to 30% of medicines in some regions may be counterfeit or substandard, particularly in rural areas where regulatory oversight is minimal; this serves as a breeding ground for the misuse of antibiotics and potential increased antibiotic resistance.
Figure 3: A street vendor in Haiti informally selling pharmaceuticals.
Source: NPR
Vaccine Inequity and the Struggle for Health Security Justice
There is much to draw from an equity lens from the COVID-19 pandemic as we saw the striking disparities in vaccine availability between Haiti and its regional partners where Haiti became the last country in the Americas to initiate a vaccination program. Less than 4% of the Haitian population received a single COVID-19 vaccine dose in comparison to the neighboring Dominican Republic where 67% of its population received a single dose. This stark contrast underscores a pandemic preparedness negligence and vaccine inequity that cannot be overlooked when aiming to build a resilient health system. While Haiti’s response to the pandemic revealed immense capacity and structural challenges, including inadequate laboratory supplies, human resource deficits, and insufficient biosecurity measures, we cannot deny the unfairness that exists at the global level in addressing health emergencies in low-income countries.
Fairness in prioritizing vulnerable populations amidst global health emergencies in the Global South continues to mark a controversy amidst the WHO’s declaration of Monkeypox as a Global Emergency. Haiti was the first country in the Caribbean to report a suspected case of monkeypox in 2022, yet laboratory constraints meant that the case had to be examined in the United States. Despite the ongoing risk of monkeypox and other health crises, Haiti still lacks widespread access to the monkeypox vaccine, further exacerbating its vulnerabilities.
Criticism of the disparities in vaccine availability surmounted as high-income wealthy countries outbid countries in the Global South for procuring the Mpox vaccine. This is further reflected by the decision of the US Government to select Nigeria as the first African country to receive the Mpox vaccine, while the outbreak's epicenter was mainly in the DRC. While the decision reflects Nigeria’s success in improving its pandemic preparedness, the inconsistency in vaccine access throughout countries in the Global South including Haiti raises the question: Is the International Community genuinely attentive to the needs of the most vulnerable nations? And how are global health initiatives positioned to meet countries in need where they are to foster true resilience?
Disparities in financing global health security and pandemic preparedness and response continue to be major hurdles for Haiti. In 2024, the WHO launched a $1.5 billion emergency appeal to respond to health crises in 15 high-level Grade 3 countries facing humanitarian conflict including Haiti. Of the $1.5 billion only $22.5 million of that appeal has been allocated to Haiti mainly to address the resurgence of cholera. While significant engagement is needed to avoid a similar 2010 cholera outbreak, financing health emergencies through a vertical funding scheme where funding is crowding in on one epidemic-prone disease neglects an integrative financing approach that fosters health system strengthening for Haiti.
A Way Forward; Policy Shifts for Sustainable Pandemic Preparedness in Haiti
As Haiti continues to grapple with political instability and infrastructure challenges affecting its health system, there must be a way forward to support a sustainable pandemic preparedness and response plan. This will require significant leadership of the Haitian government and policy shifts from the international community to address disparities within the global health security ecosystem and ensure that vulnerable populations are not left behind in the fight against AMR and other public health threats.
Reforms among donor policy within international organizations like the Vaccine Alliance (GAVI) and multilateral financing initiatives like the Global Fund to Fight Aids, TB and Malaria (GFATM) should consider the fiscal constraints of low-income countries like Haiti and implement differentiated co-financing and sustainable health financing models. Global initiatives should be held accountable for not delivering on their promise of ensuring equitable distribution of health commodities. This is further supported by the failures of the COVAX facility, which contributed to the significant delay in the distribution of COVID-19 vaccines in Haiti resulting in a two-month plus wait period for Haiti to receive 130,000 of the 750,000 vaccines promised.
Sustainable pandemic preparedness cannot be achieved by continuing to sideline the voices of low- and middle-income countries during critical decision-making processes. The call for a scaled-up response to pandemic preparedness and response in Haiti and countries of hardship must be achieved through an equitable approach and decisive action that emphasizes building resilient health systems and positioning metrics that help meet countries where they are in global health goal setting.
About the Author
Sabine Bernard, MPH is a Haitian-American global health and international development expert and Founder of Smart Dev Global, a boutique consulting firm promoting equity and inclusion in the global health & international development financing sector.
Haiti Policy House is not-for-profit institution focusing on Haitian public policy issues. Its research is nonpartisan. Haiti Policy House does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).
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