Childhood Malnutrition in post-earthquake Haiti


Thank you for your generous support of Partners In Health and our Childhood Malnutrition in Haiti project on globalgiving.  We are excited to share a selection of photos taken by Rebecca Rollins in Cange, Haiti, documenting our work to eliminate unnecessary suffering and death by providing free comprehensive health care for children, including treatment of malnutrition. With many other child-centered programs in the poor communities where PIH works, we offer children the same essential rights and services that have virtually eliminated deaths from common childhood ailments in rich countries.  We are deeply grateful for your support in making this work possible. 

1) December 10, 2012, Cange, Haiti, Steve is a three year old orphan living on the campus at Cange. His mother brought him to the clinic sometime around September 2012 for treatment for malnutrition. He was admitted and recovered, but his mother never returned.  

2) and 3) December 10, 2012, Cange, Haiti, Children at the Cange malnutrition clinic are measured, weighed and fed.

4) December 10, 2012, Cange, Haiti, A child suffering from malnutrition at the pediatric inpatient unit in Cange is fed nourimanba by his mother.  


Haiti, Three Years after the Earthquake

Posted to the PIH website on January 11, 2013 

Three years ago, Haiti experienced a devastating 7.0 earthquake that killed nearly 300,000 people and shattered the country’s infrastructure.

We remember and mourn those who were killed—friends and colleagues, mothers and fathers, brothers and sisters—as well as those who continue to suffer its effects.

Since then, Partners In Health and its Haitian sister organization Zanmi Lasante (ZL) have continued to provide health care to hundreds of thousands of people, including earthquake survivors, with the help of our supporters and partners. We created the Stand With Haiti Fund to address the immediate needs of victims and to work alongside the Haitian government to build and renovate the country’s public health infrastructure, strengthen its public medical education system, and expand PIH’s programs for community development and poverty alleviation.

PIH has fulfilled its pledge to spend the $123 million raised after the earthquake on these efforts. While there is much still to do, the following are examples of some of our work in Haiti.

Hôpital Universitaire de Mirebalais (HUM)

PIH completed construction of the $17 million, 300-bed national public teaching hospital that will open in March 2013. Located 30 miles north of Port-au-Prince, the hospital will provide primary care services to nearly 185,000 people in Mirebalais and central Haiti, and provide advanced care to patients who are referred to HUM from community hospitals throughout the Central Plateau and Artibonite departments, as well as parts of Port-au-Prince. The teaching hospital will eventually employ up to 800 Haitian staff and serve as the first university teaching hospital in central Haiti, providing residencies and clinical rotations for Haiti’s national medical and nursing schools.

In addition, the hospital’s 1,800 solar panels will produce 100 percent of its energy needs during peak daylight hours and feed surplus energy back into the grid, the first agreement of its kind with Électricité d’Haïti.

HUM is PIH’s largest undertaking to date and will improve both the standard of health care for Haitians and strengthen Haiti’s public health infrastructure.

Mental Health Care

PIH responded to the psychological needs of Haitians affected by the earthquake by more than doubling the size of its mental health and psychosocial support team. This work is supported by a recent $1.5 million Grand Challenges Canada grant to improve mental health care in countries affected by disaster and poverty.

In 2013, PIH will train community health workers to identify and support people suffering from mental health problems, including depression and post-traumatic stress, and refer them to appropriate medical facilities. A pilot program will also incorporate the use of mobile phones by community health workers to diagnose and refer patients. The new program will develop a decentralized model of mental health care to be expanded nationally in Haiti.

Oral Cholera Vaccine Campaign

Cholera has killed 7,750 people in Haiti since October 2010. In spring 2012, PIH successfully pioneered Haiti’s first oral cholera vaccine, delivering vaccines to nearly 100,000 people in partnership with Haiti’s Ministry of Health and the nonprofit organization GHESKIO. Since then, the World Health Organization has called for the creation of a global stockpile of 2 million doses of the vaccine.

The United Nations recently included the use of the vaccine as part of a $2.2 billion plan to eliminate cholera in Haiti and the Dominican Republic. Dr. Paul Farmer, PIH co-founder and U.N. Deputy Special Envoy to Haiti, has been appointed U.N. Special Advisor for Community-Based Medicine and Lessons from Haiti as part of this cholera elimination plan.

Treating Malnutrition

In partnership with Abbott Laboratories and the Abbott Fund, PIH will open a new production facility in early 2013 to combat the long-standing challenges of malnutrition. Located in Corporant, the facility will be used to produce a minimum of 60 tons of Nourimanba (a ready-to-use therapeutic food) to treat up to 6,000 cases of pediatric malnutrition in its first year.

The factory will create dozens of jobs and provide a guaranteed market for more than 250 local peanut farmers. This project also will be integrated into PIH’s agricultural initiatives to improve local farmers’ skills and expertise and strengthen their ability to supply the facility with a reliable supply of high-quality peanuts. Nourimanba has been locally produced and distributed by PIH on a smaller scale since 2006.

Our work of accompaniment is not over. We will continue to provide high-quality care to our patients, and to work with the Haitian government and communities to build and strengthen public health systems. As we remember those who lost their lives, we stand in solidarity with the millions of Haitians who are rebuilding their country, while also mobilizing around all that is left to do.



The following blog post written by Gillaine Warne, Director of Zanmi Agrikol, was published by The Huffington Post on October 25, 2012:

A Definite Cure for Malnutrition

It has been said that hundreds of thousands of dollars and equally as many hours have been spent searching for a cure for malnutrition. The good news is that a cure has been found -- it's called FOOD!

Every day of the year my thoughts turn to countries where food is a precarious commodity. These are countries where we should concentrate our efforts on sustainable solutions rather than short-term fixes.

I work in the Central Plateau of Haiti, which suffers from the highest rate of malnutrition in the country. Families struggle to provide their children with just one meal a day. I've witnessed mothers walking barefoot for days across mountains with a baby dying from malnutrition in their arms, looking for help. Throughout Haiti, one of every three children under five years old suffers from malnutrition -- and that was before the 2010 earthquake.

Zanmi Agrikol is the agricultural arm of Zanmi Lasante (Creole for "Partners In Health"). As an organization dedicated to breaking the cycle of poverty and disease, we have chosen to reach out to families who have children in special programs for severe malnutrition and are being treated with Ready to Use Therapeutic Food (RUTF). We believe that by getting to the root causes of malnutrition we can help create effective and sustainable change.

Haiti is a rural country with the potential for its people to become prosperous and well-fed. Unfortunately, the lack of education and environmental management has led to depleted, non-productive soil. Erosion has taken away much of the arable land. Cutting trees for charcoal causes deforestation, which leads to mud from the barren hillsides sliding into the sea and taking with it the last vestiges of green and growth.

Our programs at Zanmi Agrikol educate farmers about new and proven ways of planting, conservation, reforestation, and animal husbandry. We're introducing improved strains of crops and vegetables not previously available, teaching families the all-important building blocks of good nutrition, explaining what foods should be given to children each day, and underlining the importance of sustainable farming with seasonal management. Animals, such as goats, provide stopgap funding during times of crisis, including crop failure due to drought or floods. Animals are a kind of "living bank" and are integral to any program dealing with food security.

Through our Family Assistance Program we are empowering families to grow their own food, and through their own efforts combat the crisis that so often takes the lives of their children. Our program gives families, tools, seeds, trees, education, and a goat. Seeds are returned after the first harvest with a small amount of interest to introduce business principles.

A baby goat is also handed on to another family, encouraging the principle of "helping thy neighbor." The circle is enlarged, and will continue to grow.

We want to enable each family to produce sufficient food for themselves, and enough excess to take to market. Improving the quality of local markets can significantly strengthen communities. Fruit trees are being planted in great quantities, particularly the hugely popular mango. Their increased yields are allowing families and communities to form cooperatives and combine their goods in order to access larger markets.

By the way the local markets are quite something to visit with everything, including the kitchen sink, being available -- goods being spread out mostly on the ground in large and small quantities and varying degrees of quality. Clothing, furniture, chairs, hats, millions of second hand shoes, alcohol, dried fish, spices and condiments, fruits, meat and poultry both alive and otherwise, adding to the joyous cacophony of sound, and of course the produce of the local farmers being proudly displayed!

Thanks to our Family Assistance Program, more food is now becoming available, children are going to school with food in their tummies, and we are starting to see huge differences in class participation and performance. We are also working on small school vegetable gardens to help supplement the one meal given to students and underline, once again, the importance of fresh food.

Our programs can be easily "transplanted" to other communities and areas where children are suffering from malnutrition and lack of food. To be able to expand this program what we need is more participation and more funding to help more families grow real food. Our pilot program started with just 20 families and to date we have enrolled and helped more than 1,500 families. If we count about 10 members per family, that amounts to having touched nearly 15,000 hungry people. The restoration of pride and dignity to families once bowed down under the weight of desperation and hopelessness is wonderful to witness. We are now seeing heads held high and positive attitudes toward a changing future.


We hope you enjoy reading the article below, written by David Brown and published by the Washington Post on August 30, 2012.  The article highlights a project lead by Partners In Health, World Vision, and the Haitian Ministry of Health, which focuses on a holistic approach to ensuring good health among children and families living in Haiti's Central Plateau.

With your support, Partners In Health is able to continue maximizing the value of our partnerships, allowing us to create sustainable solutions for complex problems in the poorest communities of the world.  Please accept our most sincere gratitude for your generosity.


Personal coaches help Haitian families try to get out of poverty

BOUCAN CARRE, Haiti — The people who live in this part of Haiti’s Central Plateau need more of pretty much everything that makes life safe, comfortable and predictable.

Three-quarters of families do not have enough food and two-thirds do not have access to clean water. Thirty percent of households are headed by women, and 40 percent of children are not in school. One in four children is unvaccinated, and half are underweight. About 80 percent of houses do not have latrines, and 60 percent of farmers do not own the land they cultivate, according to a survey of 5,200 families in the commune, or county, of Boucan Carre.

Is it realistic for people to make headway against so many problems on their own? Several centuries of poverty would suggest the answer is no.

Would a personal assistant help? An experiment here may answer that.

Half of the commune’s 10,000 households are being assigned a “household development agent” — a neighbor who will work as a health educator, vaccinator, epidemiologist, financial analyst, social worker, scheduler and advocate all at the same time. With the agent’s help, a family will assess its needs and come up with a plan to make things better.

“The idea is to forge a relationship from the get-go,” said Maryanne Sharp, an official at the World Bank, which is overseeing the $4 million project. “We want the family to say, ‘Yes, we own the plan, and we will work on these objectives on this timetable.’ ”

The commune’s other 5,000 households will function as a control group, continuing as they have, scrounging out a living in one of Haiti’s poorest and most isolated places.

In two years, the families will be resurveyed and their children and houses reexamined. If those with agents are doing better, then the strategy of coaching people out of poverty may be expanded throughout the country.

The experiment, aided by Haiti’s health ministry and run by two charities, Zanmi Lasante and World Vision, acknowledges several realities of life here.

One is that fixing just one of a poor family’s many problems — say, access to medical care or substandard housing — may not make much difference. The second is that house calls are the most efficient way to reach people in rural areas. The third is that finding help in a place where more than 900 nongovernmental organizations operate — and provide 70 percent of the health care — can be daunting and confusing.

The all-encompassing nature of the job is not the only unusual feature of the project, which is called Kore Fanmi — “family support” in Creole. The agents will also be eligible for pay-for-performance (P4P) bonuses.

“If their families perform better, they will receive more salary,” said Francesca Lamanna, a World Bank economist who oversees the project. “This will help them do their jobs better.”

P4P is rapidly becoming a feature of American medicine, including with Medicare. But it is “kind of a new fad in global health,” said Amanda Glassman, an economist at the Center for Global Development in Washington. Evidence suggests it improves outcomes, at least for a while. Critics worry that it may lead to people gaming the system and undermine professionalism.

“These World Bank experiments are going to be very useful to generate knowledge, not just for Haiti but for other countries that are interested in doing this,” Glassman said.

Three communes are getting agents. Boucan Carre has a population of 50,000. About 3,200 people live in town; the rest live in smaller settlements down numberless tracks and footpaths.

Zanmi Lasante, the organization co-founded by physician Paul Farmer, has worked in the area for more than two decades and is running the development-agent experiment. On a recent day, commune leaders were invited to come hear about it.

The town is 45 minutes up an unpaved road from the highway. The trip in is a glimpse of life in a Haitian valley.

A man in a black suit and a woman in a white dress saddled horses to go to a funeral. Three men stopped at a stream the road crosses to wash their motorbikes. Girls in school uniforms and matching hair ribbons walked past tethered goats grazing, farmers hoeing and people sitting. Some of the houses are detailed in pastel colors; others are covered with cracked stucco tinted merely by dust.

On a hillside above town, the 21 community leaders sat in a gazebo with a roof held up by concrete pillars. All were men. They included several pastors and at least one voodoo priest. Leading the discussion was Adrienne Noel, a 40-year-old nurse with Zanmi Lasante. Her T-shirt had a slogan in Creole saying approximately, “The great national effort for the health of children.”

She told them that the agents were already collecting information about each household — the data included measurements of each child’s arm circumference to gauge nutritional status — that would be used to calculate a “vulnerability score.” The score would determine the priorities of the development plan and the frequency of visits, up to twice a month.

Twice monthly, Noel said, the agents would hold gatherings called “rally posts” at which they would immunize children or hold educational sessions for targeted groups, such as teenagers and young mothers. Each agent would have an up-to-date “opportunity map” — essentially a Yellow Pages to government offices and charities, the services they offer and how to apply for them.

She emphasized, however, that Kore Fanmi is not a giveaway program. There have been many of those in Haiti, especially since the earthquake of January 2010.

“It is important to have the family contribute. If they get help building a latrine, the family can at least dig the hole or carry the materials,” Noel said. “It is important not to promise things, because people would then expect you to do things for them.”

After three hours, the meeting wound down. Lunch — beans and rice, chicken and vegetables — was brought in from town in urns and dished into plastic bowls.

Most of the men had met the agents in their communities. The meeting nevertheless was a revelation to many.

“I now realize the program isn’t about getting a free house, or sacks of rice and containers of oil,” said Francois Charles, a 37-year-old wearing a red Carlsberg beer shirt. “It is about working with people.”

“And working with people with respect,” said a man a few seats away.

The group stood, and a man prayed and wished everyone a safe trip home. A few who lived close by stayed around and helped clean up, tossing chicken bones to dogs scavenging beneath the gazebo.

The agents

The agents, about 50 of them, arrived the next day and gathered in the same gazebo. The meeting began with the singing of a hymn.

Hired in January, they have on average a ninth-grade education. Even with that level, which was lower than planned, few women qualified.

They spent multiple week-long stays in the nearby town of Hinche learning what a vaccine does, how to calculate a dosage and how to give an injection. They learned about ways to purify water and get a micro-finance loan. They learned how to raise consciousness, even as theirs was being raised.

“The human rights framework is a very new view for a lot of them,” said Kate Thanel, a 28-year-old American employee of Zanmi Lasante who helped write the illustrated booklets the agents use. “Things like domestic violence and the rights of women and children are things we’re just starting to talk about in these rural areas.”

Each agent is assigned about 100 families. The salary is $177 a month. (One woman quit a $125-per-month job as a teacher to become an agent.) They are eligible for a 20 percent bonus based on their performance, as judged by records and audits, and on the improvements in their families’ status, as judged by things such as children being in school and fully vaccinated.

One of the agents is 22-year-old Mirlande Renelien. She and her husband live on rented land in a 20-house settlement called Trenka. They grow corn, wheat and millet, and hope her salary will allow them to also buy some animals.

Renelien, in a bright green top, stood out not only because she was one of the few women but also because she was seven months pregnant. She had walked five hours to the meeting.

The meeting did not get finished until midafternoon — too late for starting the trek back to Trenka. Renelien would spend the night with a cousin in Boucan Carre.

Carrying her Kore Fanmi backpack, she headed down the hill into the village. At dawn, she would trudge back home, one weary soldier in a battle to make life in Haiti a little bit easier.


Zanmi Agrikol: Fighting Pediatric Malnutrition in Haiti

In Haiti, the prevalence of malnutrition rates among children is tragic: according to the World Bank, nearly one-third of all children under five suffer from stunted growth and three-quarters of children 6-24 months are anemic, making Haiti’s malnutrition rates among the worst in the Latin American and Caribbean region.[1] The prevalence of malnutrition among children is especially troubling in rural Haiti. At our clinics, almost all of which are in rural areas, malnutrition accounts for 30-40% of all pediatric visits, and up to 50% during certain times of the year. Malnourished children are at risk for disease and death; prolonged malnourishment can lead to cognitive and physical delays in development.[2]

In response to this widespread need, PIH/ZL has developed an elegant solution that leverages local resources to treat the thousands of malnourished children who present at our clinics throughout the year. Zanmi Agrikol (“Partners In Agriculture”) is PIH/ZL’s broad-based nutrition program that encourages the local production of crops and uses them in the production of ready-to-use therapeutic food for the treatment for pediatric malnutrition. Zanmi Agrikol has three main components:

1)      Local production of Nourimanba for the treatment of malnutrition

Children who come to our clinics suffering from severe malnutrition are given Nourimanba, a ready-to-use therapeutic food made of five simple ingredients: locally-sourced peanuts, milk powder, vegetable oil, sugar, and a specially formulated vitamin mix. This highly nutritional treatment leads to dramatic clinical improvements, bringing children back to full health in a few short weeks. Because treatment with Nourimanba can be administered by parents in the home, children are spared long stays in the hospital.

2)      Locally sourcing Nourimanba ingredients

When PIH/ZL first recognized the success of Nourimanba in combating childhood malnutrition, we also saw a unique opportunity to increase the livelihoods of local farming families. To this end, we operate a 35-acre production farm in Corporant to grow the main ingredient of Nourimanba– peanuts. ZL employs farmers at the Corporant farm for various lengths of time depending on need. We also contract with local farmers to grow peanuts, which we purchase for use in producing Nourimanba.

Two elements make this arrangement particularly sustainable and beneficial to local farmers. First, the program includes a seed bank that provides the initial peanut inputs for local farmers, many of whom lack the initial capital to purchase seeds. After their first harvest, the farmers then return an equivalent amount of seeds at the end of the growing season, ensuring that the seed bank will be able to continue to provide seed to future farmers. Second, this arrangement provides the farmers with much-needed capital on a predictable schedule and in sufficient quantity to enable them to invest in new tools, land, and other inputs, which they are typically not able to do if they are selling their crops piecemeal on the local market.

3)      Breaking the cycle of poverty and malnutrition by providing agricultural assistance and training to vulnerable families

The final component of Zanmi Agrikol works to break the cycle of poverty that leads to such high rates of childhood malnutrition on rural Haiti to begin with. To improve long-term food security for some of the most vulnerable families we encounter in the malnutrition program, PIH/ZL provides seeds, tools, goats, trees and agricultural training through an initiative called the Family Assistance Program. Families most in need are identified by ZL clinicians and social workers for enrollment in the program. We provide seeds and tools to the families for use on their lands; occasionally we have also helped rent land for families. The families grow food for subsistence or for market, and keep any profits that result. In addition, families receive a female goat, which then serves as the equivalent of a bank account, meaning that offspring or the goat can be raised and sold at market when a household is in need of cash. 

Ongoing, individualized support and training to participating families is provided through ajan agrikol, community members who are trained by ZL agronomists to work directly with farming families on their own land. Recognizing that local farmers often have the wisdom and knowledge necessary to improve their yield, but have simply lacked the income and tools to do so, ajan agrikol enter into dialogue with each family in order to best understand their particular circumstances and determine what form of intervention will be most effective. Each ajan agrikol is responsible for visiting 10-15 families in their fields once every two weeks but often visit weekly during the rainy season.

In addition to ongoing support from ajan agrikol, families receive training through Zanmi Lasante agronomists, who train the families in better farming practices, soil conservation, tree conservation, how to farm on sloped terrain in order to maximize water distribution and minimize erosion, and how to build tools that measure the steepness of terrain and identify prime areas for farming. These trainings not only increase farmers’ skills but also help them develop farming methods that are environmentally friendly.

[1] World Bank, Promoting Nutrition Security in Haiti: An Assessment of Pre- and Post-Earthquake Conditions and Recommendations for the Way Forward, September 2010,, p. 2.

[2] Ibid., p. 3. 

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Map of Childhood Malnutrition in post-earthquake Haiti