The following is an edited update of a blog post by Dr. Timothy Schwartz (a statistical anthropologist, who has lived in Haiti for the past three decades) on Mar. 18, one day before the first two official cases of Covid-19 in Haiti were announced. This update is published two weeks later, and there are now officially 15 Coronavirus cases in Haiti and 1,109 (with 51 deaths) in the DR. Nonetheless, these figures are surely lower than reality, and many of the hypotheses and observations about testing and government conduct made here may prove relevant and prescient if there is an explosion of cases on Hispaniola in the coming days. And even if there is an explosion, we may not know… ever.
Kim Ives
The issue of when Coronavirus arrived in Haiti and the Dominican Republic has not been addressed by researchers yet. There is very little information online. And what I’ve been reading from government press releases strikes me as grossly misleading. So here’s my take on it.
Based on network analysis and simple statistic probability associated with the spread of contagious diseases, there is simply no way that Coronavirus did not arrive in Haiti and the Dominican Republic before March. Here’s the logic:
1) First of all, let’s be clear, the Haitian authorities have no clue whether Coronavirus is loose among the population, and the Dominicans are the last country on earth that is going to admit they have any disease that might stymy the flow of tourists. First the Haitians.
In the best of times, the Haitian medical system is ill-equipped to diagnosis anything. I could share dozens of personal experiences with bogus lab results over the past 30 years, such as getting diagnosed twice with worms when I had none, and then they failed to identify the worms in three different lab tests when I, in fact, did have them; twice testing me positive for typhoid when I did not have it; once testing me negative for typhoid when I did have it; once testing me negative for hepatitis A when I was Coca-Cola-colored orange with it. In fact, looking back on it, out of the 10 or so times I’ve used labs in Haiti, I may never have gotten a proper diagnosis. And mind you, I’m not an indigent patient. I’m seeking the best care in the country and paying top dollar for my tests.
That’s at the top of the social system and in the best of times. For Haiti, most people are living much closer to the bottom, and we happen to be experiencing the worst of times.
While the world has been dealing with Coronavirus, the population of Port-au-Prince has been traumatized by a kidnapping epidemic. Many of us are not even sending our children to school anymore. Many middle and upper-class people are only leaving their compounds when they have to. So who’s doing the testing? In fact, just what are they testing with? Even organizations as prestigious and well-funded as Partners in Health still do not have test kits. PIH doesn’t anticipate getting them to Haiti before Mar. 30. And for those who do not know it, PIH runs the best medical facilities in Haiti.
If what I’m saying is not enough to convince you that Haiti is not testing for the virus, note the Mar. 6 Voice of America article that directly contradicted the official announcements of Haiti’s Health Minister, Marie-Greta Roy Clément, detailing all the steps Haiti’s flagship government hospital was taking to deal with the possibility of the virus. Specifically, Dr. Jacques Mackenzie, who works at the General Hospital, told the VOA reporters:
“It’s sad to say this but the hospital receives a lot of patients daily and we are not — I repeat — we are not ready, as far as I know, to diagnose a person who has the coronavirus,” he said, adding that they don’t even have the test to determine if someone is infected.
“The diagnosis is biological so the laboratory has to confirm the diagnosis. We don’t have the test. We, the medical personnel, have not received any instructions at all with regards to detecting coronavirus cases, nor how to protect ourselves. We are seeing [in the news] all the equipment other countries have to deal with the coronavirus, their doctors, their technicians are well equipped. We, on the other hand, have never received anything that would allow us to face the possible arrival of coronavirus in the country.”
Similarly, Nurse Mary Catherine, who also actually works at the hospital, told VOA that she had no idea what the minister was talking about:
“The Ministry of Public Health has never discussed with us its policy for what to do when we receive the first coronavirus case in Haiti. The General Hospital is the first place people come. It’s people’s ‘go to’ place when they are ill. But nothing has been said, nothing has been done about the eventuality of coronavirus.”
The reports of Haitian authorities testing people at the border and claims to quarantine those with symptoms is simply show. Yes, they claim to have put some 15 people up in a hotel after someone died in a bus at the border. But it was pure show.
Similarly, there are people at the border and in the airport who take temperatures with a laser gun, as they took mine when I flew into Haiti on Feb. 12. That’s to detect fever. But again, pure show. What do they do if they detect a fever? What could they do? Forget about the fact that out of the 10,000 of thousands of people they’ve put the thermometer to the head of, something like three were reported to have a temperature – highly unlikely – and the government has zero capacity to quarantine anyone who does. It would be a nightmare for the State. One has to laugh at the thought that the Haitian State could or would give shelter, bed and meals to anything more than the dozen people it “quarantined” in the hotel mentioned above. The Haitian government doesn’t even feed dying patients at the General Hospital. The prisons are among the most inhumane on the planet. The Haitian State does not even have control of most neighborhoods in Port-au-Prince. In the past two months, many have fallen under complete control of armed street gangs, such that the National Police cannot even enter the largest popular neighborhoods, hence the kidnapping epidemic.
The Haitian State is doing what it always does: pretending like they’re conforming to standards so they can take money from the international community
No. The Haitian State is doing what it always does: pretending like they’re conforming to standards so they can take money from the international community for doing so. In their defense, the Haitian government is helpless to do anything else. Later the situation and incentives will switch. PIH and other charitable medical organizations will be using their test kits – when they finally get here – and they’ll have evidence of the virus. Then the strategy will switch, and we can expect recognition of a massive epidemic and requests for aid.
So anyway, whatever your take on the Haitian State, whether or not you take issue with any nuances of my argument about them, we can assume [on Mar. 18] they are not testing. And if they are, it’s only a small and select group of people coming into the country at official points of entry.
Now the Dominicans:
The Dominicans are only testing people getting off of planes. [On Mar. 18, there were 34 official cases, the first having been discovered Mar. 1 in Bayahibe.] I get that by reading between the lines. In the news media they only report on people coming into the country. They offer no other data.
Plus, there is simply no way the Dominican government would admit that a virus is loose among the population. Not before the whole world has it and maybe not even then. It’s all about tourism for the Dominicans. They’ve had enough bad press on that count in recent years. Quite probably, to avoid the complications of having to admit there is a high incidence of Coronavirus, the Dominicans are simply not testing anyone but tourists and returning expats.
Brianna Soukup)
So the only data we really have at the moment is the demographic data that allows us to speculate on whether the coronavirus is or should be in Haiti. And that argument begins with the fact that Haiti shares the island with the DR. If the Dominicans have the virus, the Haitians have it too. And although, like the Haitians, the Dominicans are only admitting to have a very few cases of Coronavirus, only among people coming into the country – not people among the general population. And they are only testing people coming into the country, suggesting they would rather not now if it has spread among the population. But the most important base of my argument is that the Dominican Republic is arguably the country more likely to have the virus than almost any country outside of China. Here’s that logic:
2) There are at least, at the very least, 100,000 professional Dominican sex workers and as many or more Haitians working in the DR. That’s a very conservative estimate as it fades into a gray area of hundreds of thousands of young men and women who readily engage in sex with strangers, the ideal client/partner being a foreign national who has come to the DR for sex. There have been about two million foreign visitors to the DR since the outbreak of the virus, a conservative 300,000 sex industry clients from around the world. Note as well that there is a population of retired sex tourists who bounce between the DR, Bangkok, and the Philippines. Again, Haitians are prominent among the population of sex workers in the DR.
Any virus transmitted by casual contact is going to rocket through the Dominican and Haitian populations
3) Perhaps as or more important than the Dominican sex workers in the DR are the 100,000 or more Dominican sex workers scattered around the globe. Per capita, the Dominicans must have the highest number of international sex workers on the planet. A major destination is Italy. And there is a constant flow of these women and young men going back and forth.
4) There are more than 30,000 Italian expatriates living in the DR, many are ensconced in the sex industry. If you don’t like the allegation that many Italians – as with other nationalities – patronize sex workers, then it’s enough to recognize that they are prominent as owners of hotels, restaurants, and bars, putting them in close contact with tourists and sex workers who interact intimately with tourists. Indeed, the Italian government might even have it wrong. Coronavirus might have gotten to Italy from the DR rather than vice versa. As it is, the Italian government has still not identified the source of the virus’s entry into the country. Also notable is that while I do not have the figures, I know that there is a flow of South Koreans in the DR as they have a strong presence among management and training in the offshore assembly industry, i.e. factories.
5) There are at least 60,000 Chinese in the Dominican Republic. The Chinese underworld thrives in the DR. They own and manage most of the ubiquitous sex hotels, and they use the country as a thoroughfare for illegal Chinese emigrants (first- hand experience) going to the U.S., meaning there is a steady flow of Chinese through the DR, one formal, the other illicit.
6) On top of all that, consider the close quarters, the promiscuity, drug-sharing dense population. Any virus transmitted by casual contact is going to rocket through the Dominican and Haitian populations at speeds unfathomable in say Chinese or even U.S. populations.
7) If it’s in the DR, it’s in Haiti. The border is wide open. In addition to the flow of sex workers and sexually active youth going back and forth between the two countries are some 500,000 to one million plus other Haitian residents in the DR; these people are embedded in dense and vigorous social networks that, of course, extend directly back into Haiti. If Dominicans have it, Haitians are right behind. Haitians are having sex and living with Dominicans: the sex, the bars, the shared joints, cigarettes, beers, and close living quarters, the two-hour sex hotels in many of which they might not even change the sheets.
Coronavirus’ entry and spread in Haiti could easily have been confused with the flu.
So anyway, there’s my analysis of the situation. It’s hypothetical, but there is not much else to work with at the moment. One thing is certain: while it might not be the epidemic levels I’m hypothesizing, there’s no way only 34 people as of Mar. 18 in the DR, all stepping off the plane, have it. And there is no way that no one in Haiti has it.
But let me add one more small anecdotal point and some superficial data from my own networks, including my family, and 20 some employees and colleagues many of whom live in popular neighborhoods:
Everyone in my own house in Haiti has already been sick with symptoms strikingly similar to Coronavirus, but, of course, we could not get tested. My wife and youngest child came down with symptoms on about Feb. 20. For my 6-six year-old son with mild asthma, it sent him on a 1 a.m. emergency run to the hospital on Feb. 23 for the first time in his life. For my 10-year-old daughter, it was body aches and fever for three days in early March, followed by some coughing but relatively mild symptoms. It hit me much harder than the kids. I was coughing by Feb. 23 and fever hit on Feb. 25. I typically get bronchitis after colds, and flu hits me hard. This one was the same, but it was also somewhat different. In addition to two days of fever, it infected me deep in my lungs, in a way that just seemed qualitatively different than the usual flu. It lasted for about 20 days.
As for my 20 some employees and colleagues, many of whom live in popular neighborhoods: none of them are sick and none report even a rash of cold or flu-like illness. In contrast, the consensus is that during January and February, we did have an unusual and widespread flu-like illness. A Haitian friend of my wife died unexpectedly from a respiratory crisis on Jan. 30. But few people are currently sick, and there is no run on the hospitals, no deluge of patients afflicted with respiratory complications.
As for whether or not other people in Haiti have been getting the virus: Remember the virus has come about precisely during flu season. So, in theory, its entry and spread in Haiti could easily have been confused with the flu. Moreover, it may very well be that Coronavirus will not/does not have the devastating impact on developing countries like Haiti that it has in a developed country population because, a) the population is much younger and b) many of those who would succumb to the disease in a country such as Haiti have already been killed by something else.
The Dominican Republic is slightly different. There is a substantial population of upper-class and more fragile elderly who enjoy the support of a private medical system that could have kept them alive long enough for Coronavirus to infect them. That’s something that, whether the Dominican authorities like it or not, we’ll find out soon enough.
Postscript: With some minor edits, the preceding was written on Mar. 18, 13 days ago. To bring things up-to-date: in the Dominican Republic, we now know that the virus is in fact widespread. Within two days of writing the original post, the DR went from no reports of the virus among the population to the most infected country in the Caribbean. Today they admit to some 1,109 cases and 51 deaths, which is per capita about half the number who have died in the U.S.. Again, that’s what they know about and/or admit to, and we also know that, as with Haiti — and even the U.S. for that matter — their capacity to test is extremely limited.
As for Haiti, there is still no widespread flu-like illness among the people I know living in popular neighborhoods, no reports of a deluge of clinic patients with respiratory illnesses. Yet yesterday, Mar. 30, the Haitian Health Ministry reported via Le Nouvelliste that 105 people in the country had been tested for Coronavirus. That’s still a small number of people and basically an admission from the Ministry that it had not been testing as claimed three weeks past. Interestingly, 15 of the people tested positive (~15%). Ten of those people were in the Port-au-Prince area and three in the South East Department, one in the Artibonite, and one in the North West.
Thus, while there is no suggestion in the report that there was an effort to sample the population to determine the distribution of Coronavirus (nor was it reported how many people were tested in each area), we can assume that most tests were done in Port-au-Prince and a few in these other areas. And what they tell us – given that only 105 of the population of some 11 million people were tested and 15% of them were positive — is yes, Coronavirus is already widely diffused throughout Haiti.
[As of this Mar. 31 update, officially 51 have died in the DR, and seven have recovered. In Haiti, of the 15 official cases, one has recovered, and none have died.]
