U.S. AID go home!
by John Canham-Clyne & Worth
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
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
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
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
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