U.S. AID go home!

by John Canham-Clyne & Worth Cooley-Prost

In These Times, January 8, 1996

On October 15, Tipper Gore, wife of Vice President Al Gore, set out on what should have been an

ordinary visit to a U.S. funded health clinic serving the poorest section of the capital of the poorest country in the hemisphere. But the day quickly degenerated from feel-good photo-op to fiasco. Residents of Cite Soleil, a sprawling slum on the edge of Port au-Prince, Haiti, broke up the event with a barrage of stones.

Although the U.S. press initially reported the incident as an anti-American protest, the rocks were aimed not at Mrs. Gore's entourage, but at Dr. Reginald Boulos, the Haitian director of the clinic and an influential power broker long associated with the country's right-wing paramilitaries. As Jean-Louis Eddy, a Cite Soleil resident, explained to Reuters news service in a story the next week, "[W]e have no anti-American sentiment. On the contrary, they have done a lot of good things for us."

By good things, Mr. Eddy may have been referring to the restoration of Haitian President Jean-Bertrand Aristide by U.S. military forces last year. American diplomatic and military intervention in Haiti has wrought a positive-if limited-political change: Paramilitary terror has dropped off dramatically in the last year, and people are now able to vote without being shot at.

Nevertheless, the control Haiti's democratically elected officials exert over Haitian society remains severely circumscribed by economic policy imposed by the U.S. government. While the parliamentary elections held last summer and the recent election of Aristide ally Rene Preval to the presidency have given Aristide's Lavalas movement a solid majority in the country's government, the U.S. Embassy in Port-au-Prince, and the mission of the U.S. Agency for International Development (AID) in particular, arguably remain the most powerful institutions in Haitian political life.

Given the parasitic nature of the state under Haiti's past dictators, control over economic aid has allowed AID to dominate huge swaths of the Haitian economy. Boulos' group of clinics, the Centers for Development and Health (CDS, by its French initials), is AlD's richest beneficiary in Haiti, and Boulos the most visible symbol of its influence. In their demonstration last October, Cite Soleil residents were attempting to highlight the way Boulos has used CDS as a tool of political influence. Not only does CDS generate more than $5 million a year in international revenue- it also, not coincidentally, provides a large market for Phar-Val, a pharmaceutical distributor and one of several businesses Boulos controls with his brother.

More nefarious still are Boulos' political ties. He has been linked, notably in articles by Village Voice columnist James Ridgeway and The Nation's Allan Nairn, to FRAPH, the paramilitary death squad ushered into power by U.S. intelligence during the coup led by Lleut. Gen. Raoul Cedras. It is an association that, in at least one case, has dovetailed nicely with Boulos' cozy relationship with AID. After a December, 1993 FRAPH rampage in Cite Soleil-in which dozens of homes were torched and at least 37 people died-U.S. Embassy officials took a photo-op tour of the site to announce that CDS would have complete control over $100,000 to rebuild houses and care for victims. That aid was dispensed by CDS community health workers who were members of the local FRAPH chapter. Supporters of Aristide-by far the majority of victims- could not safely claim any aid.

Boulos insists that he had no part in the violence and claims to have fired the most prominent FRAPH member employed at CDS. But two former CDS employees, interviewed by In These Times on condition of anonymity, claim to have been pressured directly by Boulos to support the coup government by organizing and participating in FRAPH demonstrations. Boulos calls these claims "outright lies."

Boulos' political ties notwithstanding, the work of his clinics raises fundamental questions about AID's long, checkered history of dubious humanitarianism. AID is the primary conduit of a host of health care, agricultural, environmental and economic programs that liberals defend as emblems of the true spirit of American generosity and that Sen. Jesse Helms derides as international welfare, or more specifically, "pouring money down Third-World rat holes." In reality, of course, AlD's humanitarian programs hew closely to the aims of U.S. national security policy, often to the detriment of the people they are ostensibly designed to help. And the agency often plays hard ball with recalcitrant governments of recipient nations. AID, the World Bank and the IMF are holding hostage millions of promised dollars in loans and aid because the Haitian government has not moved fast enough to privatize state industries despite overwhelming opposition among Haitians and their newly elected Parliament to neoliberal economic policies.

AID boasts that it delivers primary medical care to 3 million Haitians through contractors like Boulos' clinic. In fact, it has served to advance a central U.S. foreign policy priority in the Third World-population control. Nearly half of the agency's health care spending in Haiti is taken up by the Private Sector Family Planning Program, under which so-called NGOs dispense birth control methods, and each of the other programs-including the "Expanded Urban Health Services" program, which funds Boulos' CDS-has a substantial family planning component.

Through such programs, AID has aggressively promoted the use of the controversial contraceptive Norplant, plastic capsules or silicone rods implanted under the skin that release a hormonal contraceptive slowly over five years. Research on Norplant use in the developed world has shown the device to cause a range of side effects common to progestin contraceptives: headache, depression, loss of libido, weight change, hair loss, nausea and acne. Some studies indicate that as many as 80 percent of Norplant recipients experience a dramatic change in the menstrual cycle, including prolonged bleeding, heavy bleeding, spotting and amenorrhea (stopping of the cycle altogether).

These side effects, say women's health activists, make Norplant particularly unsuitable for Haiti. As many as 39 percent of women who get Norplant report prolonged or even constant menstrual bleeding for up to a year. In desperately poor Haiti, where the overwhelming majority of women already live on the nutritional edge, the bleeding poses a much greater risk of health complications- anemia, for instance-than in rich countries. Nonetheless, despite these dangers, AID deemed Third World women, including Haitians, a suitable subject population for testing Norplant-tests which ultimately led to the implant's approval by the U.S. Federal Drug Administration in 1990. Boulos' CDS was one of three sites in Haiti where studies began in 1985. Concerned about Norplant's medical impact, the Koalisyon 28 Jiye Chalmay Peral, a Haitian women's advocacy group based in New York, interviewed women and health care workers in Haiti. Their research, published in early 1991 in a Creole-language health education pamphlet entitled "Norplant: Piki Senk An" (Norplant: The Five Year Injection), found a pattern of abuses similar to those noted in Norplant trials in Bangladesh and other countries: coerced participation, the payment of incentives to workers to recruit women and refusal to remove the implant.

Once the FDA approved Norplant, AID opened the international floodgates for its distribution, particularly to Haiti. According to 1993 documents, AlD/Haiti negotiated with Washington "for provision of 20,000 sets of implants over the next two years [1993-95], which will make it the largest AlD-funded Norplant program worldwide." And as AID has enshrined Norplant as its contraceptive method of choice in Haiti, it has ignored economic as well as medical side effects. In a recent BBC documentary, medical anthropologist Catherine Maternowska reported that some implant recipients she worked with bled continuously for as long as 18 months. Haitian women, Maternowska explained, can't get Kotex or tampons; they use rags, which need to be washed every morning-"not a simple task at all in Haiti." To buy soap, women are forced to sacrifice scarce financial resources that would otherwise buy food, water, fuel and other vital necessities.

To make matters worse, AlD's push to dramatically expand Norplant use in Haiti coincided with an explicit campaign on the agency's part to facilitate birth control by "demedicalizing," or liberalizing, the delivery of all methods. A 1993 internal evaluation of AlD's family-planning programs in Haiti recommended that "breast and pelvic exams, although desirable to enhance a woman's health, should not be mandatory to obtain the pill. Changing this practice is of highest priority in terms of decreasing barriers and promoting free method choice." Like the pill and other hormonal methods, Norplant requires careful monitoring, including regular pap smears. Yet, over and over, internal AID documents dismiss mandatory pap smears, cervical exams and other health interventions as "medical barriers to contraception."

AID rationalizes demedicalization in Haiti, as in other developing countries, by arguing that the risks associated with childbirth exceed those associated with various family-planning methods. In fact, U.S.-funded family-planning programs in Haiti have been dangerously demedicalized from the beginning. In 1978, an AID pilot family-planning project sent workers to four to five households a day to distribute four cycles of oral contraceptives, four cans of foam, or a box of 100 condoms to all women aged 15 to 49. The distributors, described in a professional journal as uneducated and barely literate, were "trained" to "screen" for medical contraindications of pills-vision problems, headache, jaundice, varicose veins, breast masses, breast feeding of less than eight to nine months, and pregnancy. The screening consisted of "taking a brief history and observing the clients."

Such an atmosphere of gross negligence only compounds the danger posed to women by the already controversial drug, particularly when the implant needs to be removed. Norplant's manufacturers and distributors insist that removal is a simple procedure, but at least three separate class action suits are being prepared in the United States against the manufacturers and physicians as a result of injuries received on removal. The capsules tend to migrate in the arm, and finding them can be difficult and painful, often causing scarring and sometimes serious nerve damage. Haitian women face the same problems-when, that is, they can get the Norplant removed at all. For example, at St. Croix Hospital in Leogane, site of the 1978 pilot project, requests for removal are rarely granted. Former clinic director Dr. Judith Brown told In These Times that over a two-year period, fewer than 1 percent of Norplant users had the implant removed. A California study of Norplant acceptability, by contrast, revealed that nearly half of North American women had their implants removed within two years. This startling difference in removal rates appears to be the result of a gauntlet of financial and "community education" hurdles which Haitian women must overcome before they can get their Norplants out.

Dr. Brown insists that women who accept any contraceptive method are fully informed of the risks, side effects and benefits of the methods in advance. A woman requesting Norplant removal in Leogane must go through a series of "education" sessions. If, on a second or third visit, a woman insists, the implant will be removed. However, unless the clinic staff determines that she "has a serious medical problem," she is charged a fee of $80 [$30 U.S.] for removal within the first two years-even though AID provides it free and the fee constitutes some 20 percent of the average Haitian's annual income.

Nonetheless, Brown defends the removal fee. "Norplant is expensive," she says. "U.S. AID and the program have made a significant investment in [these women]." Boulos denounces the fees, even though CDS uses community health workers to discourage removal.

The protests against Boulos are starting to make waves beyond Cite Soleil. CDS is also home to a huge AID- and National Institutes for Health-funded medical research operation run by Johns Hopkins University, and a group of Hopkins graduate students recently called for a formal investigation into Boulos' operations. On November 5, the Johns Hopkins News-Letter published an article on the protests and the criticism of CDS by international human rights organizations. Patrick Bond, a faculty member at Hopkins' School of Public Health, told the News-Letter after a trip to Haiti that anti-Boulos graffiti is everywhere. "This is no ordinary public health clinic," Bond said. "People associate Boulos with paramilitary terrorism and, I must say, this is severely affecting Hopkins' reputation."

To his Haitian critics, Dr. Boulos represents the seamless bond between the U.S. government's ostensibly humanitarian efforts and its long history of supporting Haitian paramilitaries and dictators. Dr. Boulos sits at the nexus between the two-to his supporters in Washington and Baltimore he is a humanitarian unjustly suffering scorn from people he is trying to help. Dr. Neal Halsey, who directs Hopkins' research at CDS, defended Boulos to the News-Letter: "Being a leader means that you are automatically the target of criticism, especially in settings of extreme poverty and political instability. As a successful leader ... CDS has been the source of envy and a political target by other Haitian organizations."

Haitian women's health activist Rosann August, who received the Reebok International Human Rights award last year for her work exposing the use of rape as a political weapon by FRAPH and the Haitian military, sums up the link between U.S. political and health policy: "U.S. health policy is from the same agency that overthrew the government. [In Cite Soleil,] they've taken over every thing-health, literacy, justice. Where they've invested millions, there's no improvement in health. Eighty percent of the people are desperate and illiterate, but the programs are cosmetic and immediate. The problem is social inequality."

John Canham-Clyne is a freelance writer based in Washington. Worth Cooley-Prost, a research consultant and medical writer, is a board member of the Washington Office on Haiti.

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