protecting haiti's children: risk factors and outcomes before and since the 2010 earthquake

PROTECTING HAITI’S CHILDREN

Risk factors and outcomes before and since the 2010 earthquake

Nicholas M. Cooper

October 2012 © 2012 FXB Center for Health and Human Rights, Harvard University

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Acknowledgments.This!Report!is!intended!as!a!contribution!to!the!Government!of!Haiti,!Haitian!civil!society,!UNICEF,!and!other!organizations!advancing!the!rights!and!wellbeing!of!children!in!Haiti.!!The!views!expressed!in!this!Report!are!those!of!the!author,!and!do!not!necessarily!reflect!those!of!the!faculty,!fellows!or!staff!of!the!FXB!Center!for!Health!and!Human!Rights.!!The!author!would!like!express!his!sincerest!gratitude!to!his!colleagues!and!friends!at!the!FXB!Center!for!Health!and!Human!Rights!and!elsewhere,!whose!input,!insight,!and!assistance!added!immeasurable!value!to!this!Report!and!his!understanding!of!child!protection!in!Haiti.!!Special!thanks!must!go!to!Jennifer!Leaning!and!Arlan!Fuller,!for!their!steadfast!commitment,!vision,!and!leadership;!Megan!McLaughlin!and!Venchele!Saint!Dic,!for!their!instrumental!research!support;!Hannah!Ratcliffe,!for!her!excellent!analysis!of!both!language!and!argument;!Terra!Ziporyn,!Bonnie!Shnayerson,!Elizabeth!Newnham,!Jessica!Moore!Kaplan,!and!Mey!Cooper,!for!their!copyedits;!Elizabeth!Gibbons,!for!her!sage!counsel;!and!members!of!the!faculty!and!staff!of!the!FXB!Center!for!Human!Rights.!Without!your!guidance,!generosity,!and!wealth!of!knowledge,!this!Report!would!never!have!been!realized.!Thank!you.!!

Copyright © 2012 by the FXB Center for Health and Human Rights Harvard University 651 Huntington Avenue, 7th floor Boston, MA 02115 U.S.A. All rights reserved.

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.PROTECTING.HAITI’S..

CHILDREN..

Risk.factors.and.outcomes.before.and.since.the.2010.earthquake.

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.Nicholas.M..Cooper.

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October.2012.!

©!2012!FXB!Center!for!Health!and!Human!Rights,!Harvard!University!!

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iv! ©!2012!FXB!Center!for!Health!and!Human!Rights!

Table&of&Contents.List!of!figures!...............................................................................................................................................!vi!

Executive!summary!....................................................................................................................................!xii!

1.!Introduction!.............................................................................................................................................!1!

2.!Methodological!note!................................................................................................................................!4!

3.!Demography!.............................................................................................................................................!6!

A.!Urbanization!......................................................................................................................................!13!

B.!Vital!registration!................................................................................................................................!15!

C.!Fertility!...............................................................................................................................................!17!

D.!Child!marriage!...................................................................................................................................!32!

E.!Mortality!............................................................................................................................................!35!

F.!Family!structure!.................................................................................................................................!49!

4.!Migration!and!movement!......................................................................................................................!59!

A.!Child!migration!..................................................................................................................................!65!

B.!Child!trafficking!..................................................................................................................................!67!

C.!Adoption!............................................................................................................................................!71!

5.!Child!protection!......................................................................................................................................!74!

A.!Safety!and!security!............................................................................................................................!75!

B.!Violence!.............................................................................................................................................!78!

i.!Crime!in!the!camps!..........................................................................................................................!86!

C.!Sexual!and!gender`based!violence!....................................................................................................!89!

D.!Children!without!parental!care!.......................................................................................................!104!

i.!Orphanages!and!other!private!institutions!...................................................................................!114!

E.!Children!in!and!of!the!street!............................................................................................................!117!

6.!Poverty,!access,!and!empowerment!....................................................................................................!125!

A.!Monetary!poverty!............................................................................................................................!125!

B.!Food!security!and!nutrition!.............................................................................................................!135!

C.!Water,!sanitation,!and!hygiene!........................................................................................................!149!

D.!Shelter!and!housing!.........................................................................................................................!158!

E.!Information!and!communication!technology!..................................................................................!164!

F:!Political!and!civic!engagement!.........................................................................................................!167!

7.!Health!...................................................................................................................................................!172!

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A.!Healthcare!access!............................................................................................................................!172!

B.!Physical!health!.................................................................................................................................!179!

i.!Communicable!diseases!................................................................................................................!179!

ii.!Non`communicable!diseases!and!external!causes!.......................................................................!198!

C.!Sexual!and!reproductive!health!.......................................................................................................!201!

i.!Reproductive!health!......................................................................................................................!201!

ii.!Sexual!health!................................................................................................................................!207!

D.!Mental!and!psychological`social!health!..........................................................................................!225!

E.!Drug!use!...........................................................................................................................................!229!

8.!Education!.............................................................................................................................................!232!

A.!Early!childhood!care!and!education!................................................................................................!232!

B.!Formal!education!system!.................................................................................................................!236!

C.!Education!engagement!....................................................................................................................!248!

i.!Vulnerable!sub`populations!..........................................................................................................!270!

D.!Education!quality!.............................................................................................................................!277!

E.!Access!to!education!and!barriers!to!enrollment!..............................................................................!288!

9.!Labor!and!economic!participation!.......................................................................................................!300!

A.!Children!in!domestic!service!and!servitude!.....................................................................................!303!

i.!Types!and!definitions!of!child!domestic!service!in!Haiti!................................................................!304!

ii.!Prevalence!and!demographic!characteristics!of!children!in!domestic!service!.............................!313!

iii.!Factors!motivating!placement!.....................................................................................................!325!

iv.!Risk!factors!and!outcomes!of!child!domestic!service!..................................................................!329!

B.!Child!labor!migration!to!the!Dominican!Republic!............................................................................!346!

References!...............................................................................................................................................!354!

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List&of&figures&Figure!1:!Total!Haiti!domestic!population,!1980`2010!.................................................................................!6!Figure!2:!Population,!household!size!and!gender!ratio,!by!Department,!2003!...........................................!7!Figure!3:!Annual!domestic!population!growth!rate,!1980`2010!..................................................................!7!Figure!4:!Population!under!age!18,!1990`2010!............................................................................................!8!Figure!5:!Proportion!of!total!Haitian!population!under!age!18,!1990`2010!................................................!9!Figure!6:!Age!composition!of!surveyed!households!(hh),!February!2010!..................................................!10!Figure!7:!Haiti!population!pyramid,!2000!..................................................................................................!11!Figure!8:!Haiti!population!pyramid,!2010!..................................................................................................!11!Figure!9:!Percentage!of!population!living!in!urban!and!rural!areas,!1980`2010!........................................!14!Figure!10:!Percentage!of!Haiti's!population!in!urban!areas:!National!and!by!Department,!1982!&!2003!.!14!Figure!11:!Percentage!of!young!Haitians!who!had!first!intercourse!before!15!or!before!18,!2006!...........!17!Figure!12:!Sexual!activity!among!Haitian!young!people,!2006!...................................................................!18!Figure!13:!Sexual!activity!among!15`19!year!old!females!(percent),!2006!................................................!19!Figure!14:!Total!Fertility!Rate!(TFR),!1980!`!2009!.......................................................................................!20!Figure!15:!Adolescent!Fertility!Rate,!1997!`!2009!......................................................................................!22!Figure!16:!Percent!of!15`19!year!old!females!ever!pregnant!or!had!a!child,!2006!....................................!23!Figure!17:!Age!difference!between!women!age!15!`!24!and!their!current!partners,!2006!........................!25!Figure!18:!Contraceptive!prevalence!rate,!1997`2009!...............................................................................!28!Figure!19:!Contraceptive!prevalence!rate:!Total,!modern!methods,!and!condom,!1995`2006!.................!29!Figure!20:!Percentage!of!females!aged!15`24!who!have!ever/never!used!contraception,!2006!..............!30!Figure!21:!Percentage!of!females!aged!15`24!who!used!a!condom!at!last!sex,!2006!................................!31!Figure!22:!Knowledge!of!source!for!condoms!and!condom!use!at!first!sex,!2006!.....................................!32!Figure!23:!Age!at!first!marriage!or!union!for!20`24!year!old!females!(%),!2006!........................................!33!Figure!24:!Percent!of!15`24!year!old!females!who!are!illiterate,!by!marital!status!at!age!15,!2006!.........!34!Figure!25:!Percent!of!15`19!year!old!females!in!school,!by!marital!and!childbearing!status,!2006!...........!35!Figure!26:!Life!expectancy!at!birth:!Total,!female,!and!male,!1980`2009!..................................................!37!Figure!27:!Female!life!expectancy!as!a!percentage!of!male!life!expectancy,!1995`2009!..........................!37!Figure!28:!Probability!of!death!ages!0`19,!by!sex,!1990`2009!...................................................................!38!Figure!29:!Causes!of!neonatal!deaths,!2000!..............................................................................................!39!Figure!30:!Infant!Mortality!Rate!(IMR),!1995`2009!....................................................................................!40!Figure!31:!Progress!towards!MDG!indicator!4.2!(IMR),!1990`2005!...........................................................!41!Figure!32:!Under`5!Mortality!Rate!(U5MR),!1980`2009!.............................................................................!43!Figure!33:!Progress!towards!MDG!4!(U5MR),!1990`2005!..........................................................................!43!Figure! 34:! Disaggregation! of! U5MR! by! socio`economic! group,! sex,! urban/rural! status,! and! mother's!

education,!2000!...................................................................................................................................!44!Figure!35:!Probability!of!death!age!5`9,!by!sex,!1990`2009!.......................................................................!45!Figure!36:!Probability!of!death!age!10`19,!by!sex,!1990`2009!...................................................................!45!Figure!37:!Probability!of!death!age!10`14,!by!sex,!1990`2009!...................................................................!46!Figure!38:!Probability!of!death!age!15`19,!by!sex,!1990`2009!...................................................................!46!Figure!39:!Maternal!Mortality!Ratio!(MMR):!Reported!and!adjusted,!1995`2007!....................................!47!

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Figure!40:!Progress!towards!MDG!5.A!(MMR),!1990`2005!........................................................................!48!Figure!41:!Average!household!size,!by!income!group!and!Department,!2001!..........................................!50!Figure! 42:! Household! size! in! troubled! neighborhoods! in! Portàu`Prince,! Cap`Haïtien,! Gonaïves,! Saint`

Marc!and!Petit`Gôave,!2009!................................................................................................................!51!Figure!43:!Average!household!size!in!World!Vision!operational!areas!in!La!Gonâve,!Plateau!Central,!and!

Nord!and!Sud!Departments!following!the!January!2010!earthquake,!March!2010!............................!52!Figure!44:!Net!number!of!immigrants,!1960`2010!.....................................................................................!60!Figure!45:!Prevalence!of!lifetime!migration,!by!Department,!2001!...........................................................!63!Figure!46:!Reason!for!migrating!(%):!Youth!and!adults,!2001!....................................................................!66!Figure! 47:!Most! at`risk! population! subgroups! after! 2010!earthquake! according! to!household!heads! in!

Portàu`Prince!and!World!Vision!operational!areas,!March!2010!.......................................................!78!Figure!48:!Reported!methods!of!punishment!of!children,!by!sex!and!child!domestic!worker!(CDW)!status,!

2002!.....................................................................................................................................................!81!Figure!49:!Percent!of!surveyed!children!punished!in!the!week!before!the!survey,!by!urban/rural!status,!

sex,!and!child!domestic!worker!status,!2002!.......................................................................................!81!Figure!50:!Percentage!of!households!affected!by!rape,!murder,!kidnapping!and!gang!involvement,!2006`

2007!.....................................................................................................................................................!84!Figure!51:!Percentage!of!households!with!victims!of!aggression,!by!city,!2006`2007!...............................!85!Figure!52:!Non`consensual! sex!among!15`24!year!old! females,!by!Department!and!urban/rural! status,!

2006!.....................................................................................................................................................!92!Figure!53:!Female!attitudes!toward!domestic!violence,!by!condition,!Department!and!urban/rural!status,!

2006!.....................................................................................................................................................!99!Figure!54:!Parental!residence!in!household,!Haiti!and!Portàu`Prince!metropolitan!area,!2000!............!106!Figure!55:!Parental!residence!in!household,!by!region,!urban/rural!status,!and!child's!gender,!2006!....!108!Figure!56:!Parental!residence!in!household,!by!urban/rural!status,!and!child's!gender,!2006!................!109!Figure!57:!Parental!survival!among!children!aged!10`14,!by!gender!and!urban/rural!status,!2006!........!110!Figure!58:!Children!in!the!street!(%)!in!troubled!neighborhoods!in!Haiti,!2009!......................................!120!Figure!59:!Gini!indices,!by!Department!and!urban/rural!status,!2001*!...................................................!128!Figure!60:!Income!share!held!by!quintile!and!extreme!deciles,!2001!......................................................!128!Figure!61:!Monthly!income!(%),!2006!and!2008!......................................................................................!129!Figure!62:!Intensity!of!household!economic!activity,!by!city,!2008!.........................................................!130!Figure!63:!GDP!per!capita,!expressed!in!2005!Purchasing!Power!Parityàdjusted!2005!U.S.!dollars,!1991`

2008!...................................................................................................................................................!130!Figure!64:!Median!annual!income!per!capita,!by!Department!and!urban/rural/metropolitan!area!status,!

2001!...................................................................................................................................................!131!Figure! 65:! Household`level! monetary! effects! of! the! earthquake! in! affected! areas,! by! preèarthquake!

income!tercile,!March!2010!...............................................................................................................!135!Figure!66:!Prevalence!of!under`5!malnutrition!and!undernutrition,!1990`2006!.....................................!139!Figure!67:!Postèarthquake!household!priorities,!by!region,!February!2010!..........................................!142!Figure! 68:! Food! consumption! among! displaced! and! non`displaced! earthquakeàffected! residents,!

February!2010!....................................................................................................................................!142!

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Figure! 69:! Prevalence! of! severe! malnutrition! in! mostàffected! Departments,! by! surveyed! commune,!JanuaryÒctober!2011!.......................................................................................................................!145!

Figure!70:!Prevalence!of!moderate!malnutrition!in!mostàffected!Departments,!by!surveyed!commune,!JanuaryÒctober!2011!.......................................................................................................................!145!

Figure!71:!Price!of!basic!foodstuffs!in!Portàu`Prince!and!Jacmel,!November!2009`February!2010!.......!146!Figure!72:!Priority!areas!for!nutrition!interventions,!by!commune,!October!2011!.................................!149!Figure!73:!Access!to!improved!water!source,!by!urban/rural!status,!1990`2006!....................................!151!Figure!74:!Access!to!water,!by!income!quintile,!2001!..............................................................................!152!Figure!75:!Access!to!improved!sanitation!facilities,!by!urban/rural!status,!1990`2006!...........................!155!Figure!76:!Number!of!people!per!latrine!and!shower!in!assessed!camps,!by!Department,!May!2011!...!157!Figure!77:!Current!place!of!residence,!by!status!of!preèarthquake!residence,!March!2010!..................!162!Figure!78:!Distribution!of!IDP!camps!and!households!by!commune,!June!2010!.....................................!163!Figure!79:!Number!of!IDP!sites,!households,!and!individuals,!July!2010`September!2011!.....................!163!Figure!80:!Access!to!electricity!(%),!by!urban/rural/metropolitan!area!status!and!income!quintile,!2001

!...........................................................................................................................................................!165!Figure!81:!Total!and!mobile!phone!subscribers!(%),!1998`2009!..............................................................!166!Figure!82:!Internet!users!(%),!1998`2009!.................................................................................................!167!Figure!83:!Institutions!where!households!have!filed!complaints,!2009!...................................................!169!Figure! 84:!Geographic! variation! in! cumulative! cases! of,! and! deaths! from,! cholera,! 20!October! 2010`2!

February!2011!....................................................................................................................................!185!Figure! 85:! Cumulative! incidence! of! reported! cholera! cases! per! 1,000! population,! by! Department,! 20!

October!2010`31!July!2011!(graph)!...................................................................................................!186!Figure! 86:! Cumulative! incidence! of! reported! cholera! cases! per! 1,000! population,! by! Department,! 20!

October!2010`31!July!2011!(table)!....................................................................................................!186!Figure!87:!Trends!in!cholera!activity,!by!Department,!April`July!2011!....................................................!188!Figure!88:!Expanded!Program!on!Immunization!coverage!rate!(%),!by!antigen,!2001`2005!...................!197!Figure! 89:! Proportion! of! patients! seen! by! Handicap! International! by! age! group! compared! to! Haitian!

population,!19!January!2010.!............................................................................................................!199!Figure! 90:! Percentage! of! births! attended! by! skilled! health! personnel,! by! household! wealth! quintile,!

2003`2006!..........................................................................................................................................!204!Figure! 91:! Percentage! of! women! aged! 15`24! who! received! delivery! assistance! from! various! types! of!

service!providers,!by!Department!and!urban/rural!status,!2006!......................................................!205!Figure!92:!Mean!number!of!antenatal!care!visits!among!pregnant!females!aged!15`24,!2006!..............!207!Figure!93:!Percentage!of!young!Haitians!who!had!first!intercourse!before!15!or!before!18,!by!sex,!1995`

2006!...................................................................................................................................................!209!Figure!94:!Percentage!of!females!aged!15`24!who!used!a!condom!at!last!sex,!2006!..............................!210!Figure!95:!Knowledge!of!source!for!condoms!and!condom!use!at!first!sex,!ages!15`19!and!20`24,!by!sex,!

2006!...................................................................................................................................................!211!Figure!96:!Age!difference!between!partners!at!first!sex!among!females!age!15`24,!2006!......................!212!Figure!97:!Age!difference!between!current!partners!among!females!age!15`24,!2006!..........................!213!Figure!98:!HIV!testing!among!females!aged!15`24,!by!Department!and!urban/rural!status,!2006!.........!220!Figure!99:!Knowledge!of!HIV!prevention!methods!among!youth,!by!method,!sex!and!age,!2006!..........!221!

!List&of&Figures&

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Figure!100:!Knowledge!of!HIV!prevention!methods!among!women!aged!15`24,!by!method,!urban/rural!status,!and!Department,!2006!...........................................................................................................!222!

Figure! 101:! Knowledge! of! mother`to`child! transmission,! by! sex! and!mode! of! transmission,! 2000! and!2006!...................................................................................................................................................!223!

Figure!102:!Prevalence!of!drug!use,!by!substance,!time!period,!and!gender,!2005!................................!231!Figure!103:!Breakdown!of!pre`school!pupils,!by!gender,!section,!and!age,!2006!....................................!235!Figure!104:!Structure!of!the!Haitian!education!system!...........................................................................!237!Figure!105:!Educational!enrollment,!by!public/private!status,!2006!(estimated)!....................................!242!Figure!106:!Damage!sustained!by!schools,!Portàu`Prince,!Leogane,!and!Jacmel!(chart),!March!2010!..!244!Figure!107:!Damage!sustained!by!schools,!Portàu`Prince,!Leogane,!and!Jacmel!(table),!March!2010!..!245!Figure! 108:! Planned,! in! construction,! and! completed! semi`permanent! and! permanent! school!

reconstruction/rehabilitation,!by!commune,!March!2011!................................................................!247!Figure!109:!School!enrollment!among!10`17!year!olds,!by!age,!sex!and!urban/rural!status,!2006!.........!249!Figure! 110:! School! enrollment! among! 10`14! year! olds,! by! sex,! Department,! urban/rural! status,! and!

school!level,!2006!..............................................................................................................................!250!Figure!111:!School!enrollment!among!15`19!year!olds,!by!sex,!urban/rural!status,!and!school!level,!2006!

(chart)!................................................................................................................................................!250!Figure! 112:! School! enrollment! among! 15`19! year! olds,! by! sex,! Department,! urban/rural! status,! and!

school!level,!2006!(table)!...................................................................................................................!251!Figure!113:!Nonènrollment!among!children!age!6`17,!by!sex!and!Department,!2006!...........................!253!Figure!114:!School!attendance,!by!age!and!metropolitan/urban/rural!status,!2001!..............................!255!Figure!115:!School!enrollment!among!children!living!in!IDP!camps,!by!sex!and!age!group,!July!2011!...!256!Figure!116:!Percentage!of!children!entering!grade!1!at!the!required!age,!by!sex!and!urban/rural!status,!

1997!...................................................................................................................................................!257!Figure!117:!Trends!in!the!evolution!of!basic!education!enrollment,!by!sector,!1980`1997!....................!259!Figure!118:!Basic!education!Net!Enrollment!Rates!(NERs),!by!Department,!2000!..................................!260!Figure!119:!Number!and!percentage!of!overàged!students!relative!to!total!enrollment,!by!grade,!1998

!...........................................................................................................................................................!263!Figure!120:!Number!and!percent!of!overàge!students!in!basic!education,!1993`1998!..........................!264!Figure!121:!Number!of!overàge!students!in!basic!education,!by!sex!and!sector,!1998!..........................!265!Figure!122:!Distribution!of!students!(%),!by!grade,!1981!and!1997!.........................................................!266!Figure!123:!Student!survival!of!a!synthetic!cohort,!by!grade,!1997!.........................................................!267!Figure!124:!Dropout!rate!in!basic!education,!by!grade,!1997!..................................................................!268!Figure!125:!Highest!education!level!completed,!by!wealth!quintile,!2001!..............................................!271!Figure! 126:! Poverty! headcount! proportion,! by! education! level! and! urban/rural/metropolitan! status,!

2001!...................................................................................................................................................!272!Figure! 127:! Adolescents! not! in! school! and! not! living! with! either! parent,! by! sex,! Department,! and!

urban/rural!status,!2006!....................................................................................................................!275!Figure!128:!Girl/boy!ratio!in!primary!and!secondary!education,!1990`2005!...........................................!276!Figure!129:!Adult!illiteracy!in!Haiti,!by!year!and!sex,!1970`2000!.............................................................!286!Figure!130:!Progress!towards!MDG!2.3!(universal!youth!literacy),!1990`2015!.......................................!287!Figure!131:!Illiteracy!among!female!youth,!by!Department,!2006!..........................................................!288!

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Figure!132:!School!attendance!of!7`14!year`olds,!by!income!quintile,!2001!...........................................!294!Figure!133:!Co`residents!of!child!domestic!workers,!by!sex!and!urban/rural!status,!2002!.....................!308!Figure!134:!Restavek!kin!ties!to!household!heads!(%),!2008!...................................................................!309!Figure!135:!Matrix!of!categories!and!characteristics!of!child!placement!arrangements!.........................!312!Figure!136:!Percentage!of!children!experiencing!treatment!as!restaveks!in!five!Haitian!cities,!2008!.....!315!Figure!137:!Percentage!of!households!with!one!or!more!child!domestic!workers,!2002!........................!316!Figure!138:!Percentage!of!households!with!restavek!children,!by!survey!site,!2008!..............................!317!Figure!139:!Average!age!of!restaveks!and!restavek`boarders!compared!to!other!children,!2008!..........!318!Figure!140:!Age!distribution!of!child!domestic!workers!and!other!children!(%),!by!sex,!2002!................!318!Figure!141:!Percentage!of!restavek!and!non`restavek!children,!by!gender,!2008!...................................!319!Figure!142:!Distribution!of!child!domestic!workers!(thousands),!by!Department,!gender,!and!urban/rural!

status,!2002!.......................................................................................................................................!320!Figure! 143:! Place! of! birth! of! children! aged! 5`17,! by! gender,! child! domestic! worker! status,! and!

urban/rural!status,!2002!....................................................................................................................!321!Figure!144:!Economic!status!of!households!placing!their!children!as!restaveks!and!restavek5boarders,!by!

socio`economic!status,!2008!.............................................................................................................!323!Figure! 145:! Economic! status! of! households! containing! restaveks! and! restavek`boarders,! by! socio`

economic!status,!2008!.......................................................................................................................!323!Figure!146:! Total! and!per`person!mean!and!median! annual! household! income! (Gourdes),! by!whether!

households!have!placed!a!child!in!another!household!for&any&reason,!2002!....................................!324!Figure!147:! Total! and!per`person!mean!and!median! annual! household! income! (Gourdes),! by!whether!

households!have!placed!a!child!in!another!household!to&perform&housework,!2002!.......................!324!Figure! 148:! Percentage! of! households! receiving! restaveks! and! restavek5boarders,! by! sending! status,!

2008!...................................................................................................................................................!325!Figure! 149:! Activities! performed! by! child! domestic! workers! and! other! children! during! the! preceding!

year,!2002!..........................................................................................................................................!332!Figure!150:!Average!number!of!restavek!and!non`restavek!chores,!by!surveyed!site,!2008!...................!333!Figure! 151:! Activities! performed! by! child! domestic! workers! during! the! preceding! week,! by! sex! and!

urban/rural!status,!2002!....................................................................................................................!334!Figure!152:!Children's!weekly!workload,!in!approximate!quintiles!of!hours!worked,!by!age,!2002!........!335!Figure! 153:! Median! number! of! hours! worked! in! the! household! during! the! preceding! week,! by! child!

domestic!worker!status,!sex,!age,!and!urban/rural!status,!2002!......................................................!336!Figure! 154:! Percentage! of! children! enrolled! in! school,! by! child! domestic!worker! status,! age,! and! sex,!

2002!...................................................................................................................................................!338!Figure!155:!School!enrollment,!by!residence!with!parents!and!child!domestic!worker!status,!2002!......!338!Figure!156:!Average!years!of!schooling!of!restavek!and!non`restavek!children,!by!surveyed!site,!2008!339!Figure!157:!Percentage!of!children!punished!using!various!methods!during!the!preceding!week!(graph),!

by!child!domestic!worker!status!and!sex,!2001!.................................................................................!342!Figure!158:!Percentage!of!children!punished!using!various!methods!during!the!preceding!week!(table),!

by!child!domestic!worker!status,!urban/rural!status,!and!sex,!2001!.................................................!342!Figure!159:!Child!vulnerability!to!street! life!and!transport!to!the!Dominican!Republic,!by!surveyed!city,!

2008!...................................................................................................................................................!348

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Executive&summary&!Haiti’s!4.25!million!children!faced!a!bleak!future!following!the!earthquake!of!12!January!2010.!Not!only!did! the! earthquake! create! new! challenges! to! child! protection,! but! also! exacerbated! preèxisting!vulnerabilities! limiting! the! fulfillment! of! children’s! rights.1! Two! and! a! half! years! later,! however,!interventions! by! the! Haitian! Government,! the! international! community,! and! local! organizations! have!made!significant!progress!in!improving!child!protection!risk!factors,!and!outcomes.!Daunting!challenges!remain,!with!critical!unmet!need!in!most!social!and!economic!sectors!at!both!policy!and!programmatic!levels.!Yet!in!some!areas,!such!as!access!to!healthcare,!children!in!Haiti!today!may!have!greater!access!to!services!than!before!the!earthquake.2!While!the!destruction!of!the!earthquake!will!remain!a!tragedy!for! Haiti! and! its! children,! it! has! also! provided! an! opportunity! to! realize! the! vision! of! “building! back!better.”!!!Protecting! Haiti’s! children! requires! a! holistic! assessment! of! risk! factors! that! contribute! to! their!vulnerability!and!resilience.!For!this!reason,!“operational”!definitions!of!child!protection,!which!require!the!categorization!of!those!in!need,!such!as!child!laborers,!separated!and!unaccompanied!children,!and!children! in! contact! with! the! law,3! are! less! useful! to! inter`sectoral! decision`makers! than! information!pertaining! to! current! basic! needs! and! risk! factors.! This! report! recognizes! that! child! protection! is!inextricably!linked!to!familial!and!social!context,!and!that!outcomes!reflect!dynamic!relationships!among!risk! factors.4!Consequently,! the! report!presents! the! current! state!of! child!protection! in!Haiti! from! the!perspective! of! risk! factors,! outcomes,! trends,! and! key! gaps! in! knowledge.! This! perspective! allows!policymakers!and!programmers!to!make!evidence`based!decisions!that!will!help!build!a!better!future!for!Haiti’s!children.!!!Demographics.and.displacement.While!Haiti’s!population!growth!rate!has!fallen!to!1.3%!per!annum,!children!comprise!42.5%!of!the!total!Haitian!population,!contributing!to!a!“youth!bulge”!of!those!aged!5`14.!More!than!half!of!all!Haitians!live!in!urban!areas!and!around!one!quarter!of!the!Haitian!population!lives!in!the!Portàu`Prince!metropolitan!area.5! This! population! concentration! proved! disastrous!when! the! 7.0! Richter! scale! earthquake! struck!just!25km!southwest!of!Portàu`Prince!in!January!2010.6!Over!220,000!people!lost!their!lives,!more!than!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1!World!Bank,!World&databank&education&statistics&(EdStats).!Available!at!http://data.worldbank.org/data`catalog/ed`stats!

2!L.!Ivers,!A.!Schiff,!D.!Jones,!et!al.,!“Assessment!and!analysis!of!Haitian!HADR!data”!(presentation!to!the!Haiti!Assessments!Working!Group,!April!27!2010).!

3!UNICEF,!Child&protection&information&sheets!(May!2006).!Available!at!http://www.unicef.org/publications/files/Child_Protection_Information_Sheets.pdf!

4!UNICEF,!Child&protection:&A&handbook&for&parliamentarians,!Handbook!for!Parliamentarians!No.!7!(2004).!Available!at!http://www.unicef.org/publications/files/Guide_Enfants_OK.pdf!!

5!World!Bank,!World&development&indicator&database.!Available!at!http://databank.worldbank.org/ddp/home.do?Step=12&id=4&CNO=2!

6!U.S.!Geological!Survey,!Magnitude&7.0&–&Haiti&Region:&Details,!Earthquake!Hazards!Program!(2010).!Available!at!http://earthquake.usgs.gov/earthquakes/eqinthenews/2010/us2010rja6/#details!!

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300,000!were! injured,!and!millions!were!directly!affected.7! In!the!month!following!the!earthquake,!an!estimated! 500`600,000! people! (22%! of! the! Portàu`Prince! population)! left! the! Portàu`Prince!metropolitan! area,! although! by! the! end! of! January! 2010! migration! to! the! capital! again! exceeded!migration!from!the!capital.!By!March!2010,!the!Portàu`Prince!population!was!an!estimated!15%!smaller!than!before!the!earthquake.8!The!proportion!of!those!who!left!Portàu`Prince!following!the!earthquake!that! have! since! returned,! as! opposed! to! those!migrating! to! Portàu`Prince! for! the! first! time,! remains!unclear.! By! June! 2010,! 1.6!million! people!were! living! in!more! than! 1,300! Internally! Displaced! Person!(IDP)! camps,! including! approximately! 800,000! children.9! By! September! 2011,! approximately! 550,000!people!remained!in!IDP!camps,!of!whom!209,000!were!estimated!to!be!children.10!!Child.survival..Life!expectancy!at!birth! for!all!people! in!Haiti! increased! from!1980! (50.6!years)! to!60.3!years! in!2009,!increased! probability! of! survival! has! been! greater! for! children! than! for! other! age! groups! during! this!period.11!A!child!born!in!1990!had!an!18.2%!chance!of!dying!before!age!20.!By!2009,!the!WHO!estimated!that! this! probability! had! decreased! by! more! than! one! third,! to! approximately! 11.0! percent.!Improvements!in!survival!rates!were!observed!across!all!child!subgroups,!but!were!most!notable!among!children!under!five!and!those!aged!5`9.12!Despite!remaining!the!highest!in!the!Americas,!Haiti’s!under`five!mortality!rate! (U5MR)!fell!by!52%!between!1990!and!2009,! to!72!deaths!per!1,000! live!births.13,14!However,! the! U.S.! Census! Bureau! estimated! in! 2010! that! the! direct! and! indirect! effects! of! the!earthquake!raised!Haiti’s!U5MR!to!181!deaths!per!1,000!live!births.15!More!recent!data!are!unavailable.!!!Communicable! diseases! are! the! primary! drivers! of! total! childhood! mortality! in! Haiti,! although! non`communicable! diseases,! including! accidents,! assault,! and!maternal! causes,! are! a! greater! concern! for!those! aged! 10`19! than! for! their! younger! counterparts.16! UNICEF! has! noted! that! following! the! initial!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!7!Government!of!Haiti,!Haiti&earthquake&PDNA:&Assessment&of&damage,&losses,&general&and&sectoral&needs!(March!2010).!Available!at!http://siteresources.worldbank.org/INTLAC/Resources/PDNA_Haiti`2010_Working_Document_EN.pdf!

8!L.!Bengtsson,!X.!Lu,!R.!Garfield,!et!al.,!Internal&population&displacement&in&Haiti:&Preliminary&analyses&of&movement&

patterns&of&Digicel&mobile&phones!(May!2010).!9!UNICEF,!Children&of&Haiti:&Milestones&and&looking&forward&at&six&months!(July!2010).!Available!at!http://www.unicef.org/emerg/files/UNICEF_Haiti_`_Six_Months_Report_Final.pdf!!

10!IOM,!Population&in&camps&housing&Haitians&left&homeless&by&the&2010&earthquake&drops&below&600,000,!International!Organization!for!Migration!(August!2011).!Available!at!http://www.iomhaiti.com/ft/page.php?id=53!


12!WHO,!Life&tables&for&WHO&member&states:&Haiti.!Available!at!http://www.who.int/healthinfo/statistics/mortality_life_tables/en/!

13!WHO,!Global&health&observatory&database:&Haiti.!Available!at!http://www.who.int/gho/en/!14!UNESCO,!Data&center:&Custom&tables:&Haiti.!Available!at!http://stats.uis.unesco.org/unesco/TableViewer/document.aspx?ReportId=136&IF_Language=eng&BR_Topic=0!

15!U.S.!Census!Bureau,!International&data&base:&Haiti&demographic&indicators.!Available!at!http://www.census.gov/population/international/data/idb/informationGateway.php!

16!PAHO,!Health&in&the&Americas&2007:&Volume&II&–&countries:&Haiti!(2007).!Available!at!http://www.paho.org/hia/archivosvol2/paisesing/Haiti%20English.pdf!!

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destruction!caused!by!the!2010!earthquake,!communicable!diseases!have!once!again!come!to!dominate!Haitian!childhood!mortality.17!.!Child.migration..Child! migration! within! and! from! Haiti! is! dominated! by! the! search! for! economic! opportunity! and!education!for!both!children!themselves!and!for!their!adult!caregivers.18,19!Prior!to!the!2010!earthquake,!it!was! believed! that! every! year! between! 2,000! and! 3,000! children! illegally! crossed! the! border! to! the!Dominican!Republic!in!search!of!work,!before!returning!with!earnings!to!support!their!families.20!A!2001!survey!found!that!36.5%!of!youth!and!adult!respondents!who!had!migrated!within!Haiti!did!so!to!follow!their! family,!while!13%!cited!educational! reasons!as! their!primary!motivation.21!These!proportions!are!likely! to!be! greater! for! children,!who!were!not! surveyed,! than! for! adults,! given! children’s! reliance!on!their!family!for!access!to!basic!needs!and!their!higher!propensity!to!enroll!in!school.!!!Child.trafficking.The!detection!and!eradication!of!child!trafficking!remains!a!pressing!concern! in!Haiti.! In!2009,!UNICEF!estimated! that! 2,000! children! were! trafficked! every! year! to! the! Dominican! Republic.22! Significantly,!UNICEF! and! IOM! had! also! estimated! in! 2002! that! between! 176,000! and! 300,000! children! were! the!victims!of!child!trafficking!within!Haiti.23!The!hidden!nature!of!child!trafficking,!however,!has!prompted!the! International! Labor! Organization! to! suggest! that! these! estimates! be! considered!more! illustrative!than!exact.24!The!2010!earthquake!compounded!children’s!risk!of!trafficking,!with!7%!of!camps!in!Portàu`Prince,! 9%! of! camps! outside! of! Portàu`Prince,! and! 13%! of! non`camp! sites! outside! of! the! capital!reporting! at! least! one! instance! of! suspected! child! trafficking! in! the! first! month! following! the!earthquake.25!No!information!is!available!on!whether!these!cases!were!confirmed!during!followùp.!The!significant!risks!faced!by!trafficked!children,!including!physical,!psychological,!and!sexual!abuse,!highlight!the!urgency!of!a!comprehensive!response.!The!Haitian!Government!identified!the!need!for!measures!to!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!17!UNICEF,!Children&of&Haiti:&Progress,&gaps&and&plans&in&humanitarian&action!(April!2010).!Available!at!http://www.unicef.org/romania/FINAL_UNICEF_Haiti_90`Day_Report_13_April_2010_FINAL.pdf!!

18!H.!Lunde,!Young&Haitian&labour&migrants:&Risks&and&opportunities&in&Haiti&and&the&Dominican&Republic,!Fafo!Report!2010:!24!(2010).!Available!at!http://www.fafo.no/pub/rapp/20168/20168.pdf!!

19!World!Bank,!Social&resilience&and&state&fragility&in&Haiti:&A&country&social&analysis,!Caribbean!Country!Management!Unit,!Report!no.!36069`HT!(April!2006).!Available!at!http://siteresources.worldbank.org/SOCIALANALYSIS/1104894`1115795935771/20938696/Haiti_CSA.pdf!!

20!UNICEF,!Children&of&Haiti:&Progress,&gaps&and&plans&in&humanitarian&action!(April!2010).!Available!at!http://www.unicef.org/romania/FINAL_UNICEF_Haiti_90`Day_Report_13_April_2010_FINAL.pdf!!


22!G.!Menezes,!Warning&of&the&dangers&of&child&trafficking&in&Haiti,!UNICEF!(23!March!2011).!Available!at!http://www.unicef.org/infobycountry/haiti_58029.html!

23!U.S.!Department!of!Labor,!Findings&on&the&worst&forms&of&child&labor:&2006&report:&Haiti!(2006).!Available!at!http://www.dol.gov/ilab/map/countries/haiti.htm.!!

24!ILO,!Unbearable&to&the&human&heart:&Child&trafficking&and&action&to&eliminate&it,!International!Labour!Office!(2002).!Available!at!http://www.unicef.org/violencestudy/pdf/2002_traff_unbearable_en.pdf!!

25!CDC,!CDC&summary&of&initial&rapid&assessment&conducted&by&UN&OCHA&in&Haiti!(February!2010).!

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combat! child! trafficking! in! its! Post`Disaster! Needs! Assessment,26! and! international! partners! have!assisted! in! the! design,! implementation,! and! training! of! staff! for! trafficking! prevention! programs.!Between! January! and! July! 2010,! 6,000! cases! of! child! movement! across! the! Dominican! border! and!through! airports! had! been! evaluated,! and! 400! victims! had! been! assisted.27,28! In!March! 2011,! UNICEF!stated!that!of!the!11,774!children!screened!at!the!Port`au`Prince!airport!and!other!border!checkpoints!in! all! of! 2010,! 459!were! identified! as! victims!of! child! trafficking.29! The! relatively! small! increase! in! the!number!of!identified!child!trafficking!victims!may!be!the!result!of!a!true!reduction!in!the!number!of!child!trafficking!attempts,!traffickers’!use!of!other!routes,!or! lower!rates!of!successful! identification,!though!the!impact!of!each!of!these!factors!remains!unknown.!!Child.labor.Child! Labor! is! prevalent! in! Haiti,! despite! legislation! restricting! child! work.! In! 2005,! the! World! Bank!estimated!that!33.4%!of!children!aged!5`14!were!economically!active,!particularly!boys!(37.3%!male!vs.!29.6%! female).30! In! terms! of! employment,! 22%! of! boys! and! 19%! of! girls! in! this! age! group! were!employed,! for! an!aggregate!estimate!of! approximately!21%.31,32!Among!boys!aged!15`19,!51.3%!were!either!employed!or! looking! for!work! in!2007,!while! the!same!was!true! for!39.4%!of!girls.!As!such,! the!total! labor!force!participation!rate!for!this!age!group!was!45.4%,!with!girls!80%!as! likely!as!boys!to!be!economically!active.33!!!Of! particular! concern! in! Haiti! are! those! children! working! as! domestic! servants.! These! children! are!referred!to!as!restaveks,!a!pejorative!term.!Household!poverty!compels!many!children!to!leave!families!unable! to! meet! their! basic! needs.34,35! These! children! are! often! “employed”! as! servants! in! another!household.!Restavek!children,!in!general,!compared!to!other!children!in!the!household,!have!less!access!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!26!Government!of!Haiti,!Haiti&earthquake&PDNA:&Assessment&of&damage,&losses,&general&and&sectoral&needs!(March!2010).!Available!at!http://siteresources.worldbank.org/INTLAC/Resources/PDNA_Haiti`2010_Working_Document_EN.pdf!

27!UNICEF,!Children&of&Haiti:&Milestones&and&looking&forward&at&six&months!(July!2010).!Available!at!http://www.unicef.org/emerg/files/UNICEF_Haiti_`_Six_Months_Report_Final.pdf!!

28!UN!MINUSTAH,!Haiti:&6&Months&after…!(July!2010).!Available!at!http://www.un.org/en/peacekeeping/missions/minustah/documents/6_months_after_commemoration.pdf!!

29!UNICEF,!OHCHR&Universal&Periodic&Review&–&Haiti!(March!2011).!Available!at!http://lib.ohchr.org/HRBodies/UPR/Documents/session12/HT/UNICEF`eng.pdf!


31!UNICEF,!State&of&the&world’s&children&199752009!(Oxford:!Oxford!University!Press,!1997`2009).!Available!at!http://www.unicef.org/sowc/!!

32!UNICEF,!Progress&for&children&number&8:&A&report&card&on&child&protection!(September!2009).!Available!at!http://www.unicef.org/protection/files/Progress_for_Children`No.8_EN_081309(1).pdf!!

33!UN!DESA,!World&youth&report:&2007!(New!York:!United!Nations,!2007).!Available!at!http://www.un.org/esa/socdev/unyin/wyr07.htm!!

34!T.!Sommerfelt,!Child&domestic&labour&in&Haiti:&Characteristics,&contexts&and&organisation&of&children’s&residence,&

relocation&and&work,!FAFO!(May!2002).!Available!at!http://www.fafo.no/ais/other/haiti/childlabour/EEDH_Report_draft_english.pdf!!

35!G.!R.!Smucker,!Y.!F.!Pierre,!and!J.!F.!Tardieu,!Lost&childhoods&in&Haiti:&Quantifying&child&trafficking,&restavèks,&&&victims&of&violence,!Pan!American!Development!Foundation!Protecting!Human!Rights!Project!(November!2009).!Available!at!http://www.crin.org/docs/Haiti_lost_childhoods.pdf!!

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to!education,!are!subjected! to!greater!psychological!abuse,!are!often!emotionally!excluded! from!their!host! families,! exhibit! inferior! health! outcomes,! and! have! greater! risk! of! sexual! and! gender`based!violence.36! It! is! estimated! that! there! are! between! 90,000! and! 300,000! restavek! children! in! Haiti,37!although!enumeration! is!difficult!both!because!of!the!hidden!nature!of!the!phenomenon!and!because!there! is! no! categorical! definition! of! restavek.! One! study! estimated! that! approximately! two! thirds! of!restaveks!are!girls,!and!that!in!urban!versus!rural!areas,!a!greater!proportion!of!restaveks!are!also!girls!(72%).38! A! 2009! study! in! the! Port`au`Prince! metropolitan! area! found! that! 30%! of! all! households!contained!at!least!one!restavek.39!However,!this!finding!may!not!be!generalizable!across!Haiti!as!Port`au`Prince!is!the!preferred!destination!for!all! internal!migrants.!Interestingly,!the!survey!found!that!11%!of!household!hosting!a!restavek!had!also!sent!at!least!one!child!to!live!as!a!restavek!elsewhere.40!Similarly,!a!number!of!studies!found!that!households!in!all!income!quintiles!reported!hosting!restaveks,!although!lower!per!capita!household!income!was!a!significant!determinant!of!the!probability!of!sending!a!child!for!placement.41,42,43!!!Exposure.to.violence.Whatever! their! living! situation,! children! in!Haiti! are!also! likely! to!experience! some! form!of!violence.44!Violence!against!children! is!a!multi`faceted!concept! including!physical!and!mental!abuse,!exploitation,!sexual!abuse,!and!negligent! treatment.!While!victimization! from,!and!participation! in,!gangs! is! socially!condemned,!other!forms!of!violence!in!more!“controlled”!environments!including!schools!and!the!home!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!36!T.!Sommerfelt,!Child&domestic&labour&in&Haiti:&Characteristics,&contexts&and&organisation&of&children’s&residence,&


37!U.S.!Department!of!State,!Trafficking&in&persons&report&2009,!Office!to!Monitor!and!Combat!Trafficking!in!Persons!(June!2009).!Available!at!http://www.state.gov/documents/organization/123357.pdf!!









44!Cultural!Consultation!Service,!Mental&health&in&Haiti:&A&literature&review!(February!2010).!Available!at!http://www.state.nj.us/humanservices/dmhs/disaster/MH_in_Haiti%20_Literature_Review.pdf!!

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are!accepted!as!a!regular!part!of!child`rearing.45!A!2004!study!found!that!60%!of!women!and!85.7%!of!men! in!Haiti! reported! that! they!had!been!mistreated!at!a!moderate!or! severe! level!during!childhood.!Corporal! punishment! in! the! home! is! widely! used! as! a! method! of! discipline,! including! spanking! and!beating.! In! 2005,! the!Government!of!Haiti! stated! that! 40%!of! children!were!hit! or! beaten!when! they!behaved!badly.46!Most!sources!indicate!that!children!who!are!not!biologically!related!to!the!household!head,!such!as!paid!and!unpaid!child!servants,!are!at!greater!risk!of!physical!violence!in!the!home.!A!2009!UN!report!stated!that!70%!of!children!in!domestic!servitude!had!suffered!from!some!form!of!abuse,!and!that! 10%`15%!of! these! abused! children! had! been! sexually! abused.47! In! contrast,! a! 2002! study! by! the!FAFO!found!no!appreciable!difference!in!the!likelihood!of!physical!abuse!between!biological!and!other!children,!but!found!that!non`biological!children!were!subject!to!greater!psychological!abuse,!potentially!resulting!in!greater!harm!from!similar!levels!of!physical!abuse.48!Despite!the!training!of!an!additional!100!Child! Protection! Brigade! officers! within! the! Haitian! National! Police! since! the! earthquake,! social!acceptance! of,! and! legal! ambiguity! regarding,! violence! against! children! in! the! home! has! limited! the!efficacy!of!prevention!and!protection!initiatives.49!Similarly,!despite!its!prohibition,!corporal!punishment!remains!prevalent! in!Haitian!schools,!negatively!affecting!the!physical!and!psychological!wellbeing!and!development!of!children.50!!Despite!a!reduction!of!communal!violence!following!the!cessation!of!political!unrest!in!2006/2007,!the!security! situation! in! Portàu`Prince! deteriorated! markedly! following! the! 2010! earthquake.! Between!January! and! March! 2010,! 14%! of! Cite! Soleil! residents! reported! victimization! or! witnessing! violence!where! they!were! living.!The! leading! forms!of!violence!were!beating! (27%),! fighting! (24%),! rape! (20%),!and! theft! (18%).51! Across! earthquakeàffected! areas,! a! greater! proportion! of! people! living! in! camps!reported!threats!to!security!than!those!in!non`camp!zones.!In!fact,!nearly!half!(47%)!of!camp!residents!in! Portàu`Prince! were! victims! of! property! crimes! between! January! and!March! 2010,! while! 21%! had!been! threatened!with! physical! harm.! In! contrast,! the! same! survey! found! that! only! 2%!of! the! general!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!45!Haitian!Ministry!of!Social!Affairs!and!Labor,!Response&to&the&United&Nations&Secretary5General’s&study&on&violence&against&children&questionnaire&to&governments!(March!9,!2005).!Available!at!http://www2.ohchr.org/english/bodies/CRC/docs/study/responses/Haiti.pdf!!

46!Haitian!Ministry!of!Social!Affairs!and!Labor,!Response&to&the&United&Nations&Secretary5General’s&study&on&violence&against&children&questionnaire&to&governments!(March!9,!2005).!Available!at!http://www2.ohchr.org/english/bodies/CRC/docs/study/responses/Haiti.pdf!!

47!UN!GA,!Report!of!the!special!rapporteur!on!contemporary!forms!of!slavery,!including!its!causes!and!consequences,!Gulnara!Shahinian,!UN!Doc.!A/HRC/12/21/Add.1!(2009).!Available!at!http://www.unhcr.org/refworld/docid/4ac0c6b42.html!



49!Global!Initiative!to!End!All!Corporal!Punishment!of!Children,!Haiti&country&report!(February!2009).!Available!at!http://www.endcorporalpunishment.org/!!


51!UN!OCHA!Haiti,!Haiti:&Humanitarian&assessment&key&findings&No.&1,!22!March!2010!(March!2010).!Available!at!http://haiti.cridlac.org/XML/eng/doc90885/doc90885`contenido.pdf!!

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non`camp!population!had!been!threatened!with!physical!violence.52!The!physical!arrangement!of!camp!spaces,! including! the! location! of! latrines! and! water! sources,! bathing! facilities,! and! the! presence! of!lighting,!were!highlighted!as!a!key!risk!factor!for!violence!among!camp!residents.53,54,55!As!the!number!of!Haitian! children! living! in! camps!has! decreased! and! service! provision!has! expanded!over! the!past! two!years,! threats! to! security! and! the! risk! of! violence! are! likely! to! have! decreased! in! aggregate,! while!remaining! high! for! those! still! living! in! IDP! camps.! In! November! 2011,! the! UN! Deputy! Special!Representative! of! the! Secretary! General! for! Haiti,! Nigel! Fisher,! stated! that! violence,! in! general,! and!sexual!violence,!in!particular,!continued!in!IDP!camps,!but!with!less!frequency!than!at!the!end!of!2010.56!!Sexual! and! gender`based! violence! (SGBV),! like! physical! violence,! is! prevalent! in! Haiti! as! well,! with!children! in! domestic! servitude,! street! children,! and! child! labor!migrants! at! particularly! high! risk.! The!2010!earthquake!compounded!Haitian!children’s!vulnerability!to!SGBV!by!rendering!preèxisting!safety!nets,!prevention!strategies,!and!survivor!services!inoperable.!In!2003,!the!UN!Committee!on!the!Rights!of! the! Child! noted! that!more! than!one! third! of!Haitian!women!had!been! sexually! abused!before! age!15.57! Notably,! 24.2%! of! all! female! youth! reported! that! their! first! time! having! sex! had! been! forced.58!Female!child!domestic!servants!were!4.5!times!more!likely!to!be!sexually!abused!than!other!girls.59!!There! is! a! widely`held! perception! among! policymakers! and! service! providers! that! the! prevalence! of!sexual!and!gender`based!violence!increased!following!the!earthquake.60,61,62,63,64!While!there!have!been!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!52!UN!OCHA!Haiti,!Haiti:&Humanitarian&assessment&key&findings&No.&3,!5!April!2010!(April!2010).!Available!at!http://groups.google.com/group/assessmentshaiti/browse_thread/thread/71f3f127213f7a06!!

53!Institute!for!Justice!&!Democracy!in!Haiti,!Our&bodies&are&still&trembling:&Haitian&women’s&fight&against&rape!(July!2010).!Available!at!http://ijdh.org/wordpress/wp`content/uploads/2010/07/Haiti`GBV`Report`Final`Compressed.pdf!!

54!S.!Toupin,!Ensuring&haitian&women’s&participation&and&leadership&in&all&stages&of&national&relief&and&

reconstruction:&A&gender&shadow&report&of&the&2010&Haiti&PDNA!(2010).!Available!at!http://reliefweb.int/node/350585!!

55!UN!MINUSTAH,!IDP&camp&joint&security&assessment&report,!MINUSTAH!Human!Rights!Section!(March!2010).!Available!at!http://oneresponse.info/Disasters/Haiti/Protection/publicdocuments/Joint%20Security%20Assessment%20report%20`%20Final.doc!!

56!UN!MINUSTAH,!Press&Conference&by&Deputy&Special&Representative&of&Secretary5General&for&Haiti!(30!November!2011).!Available!at!http://minustah.org/?p=32936!

57!UN!Committee!on!the!Rights!of!the!Child,!Concluding!observations:!Haiti,!UN!Doc.!CRC/C/15/Add.202!(2003).!Available!at!http://www.unhcr.org/refworld/docid/3f2597274.html!!

58!Government!of!Haiti,!Enquête&mortalité,&morbidité&et&utilisation&des&services&(EMMUS&IV)&200552006!(January!2007).!Available!at!http://www.measuredhs.com/pubs/pdf/FR192/FR192.pdf!

59!A.!R.!Kolbe!and!R.!A.!Hutson,!“Human!rights!abuse!and!other!criminal!violations!in!Portàu`Prince,!Haiti:!a!random!survey!of!households,”!The&Lancet!368!(2006),!pp.!864`873.!


61!ALNAP,!Haiti&earthquake&response:&Context&analysis!(July!2010).!Available!at!http://www.alnap.org/pool/files/haiti`contextànalysis`final.pdf!!

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no!nationally!representative!surveys!allowing!the!quantification!of!this!increase,!available!evidence!and!experience! in! other! post`disaster! contexts! suggests! that! an! increase! is! likely! in! the! postèarthquake!context.!In!addition,!greater!proportions!of!victims!of!sexual!and!gender`based!violence!are!more!likely!to! be! reporting! abuses! now,! due! to! greater! accessibility! of! care! and! support! services.65! A! study!conducted!by!the!Center!for!Human!Rights!and!Global!Justice!at!the!New!York!University!School!of!Law!in!January!2011!highlighted!the!continuing!threat!of!sexual!and!gender`based!violence!in!IDP!camps!one!year!after!the!earthquake,!although!the!authors!noted!that!estimates!may!not!be!generalizable!across!IDP!camps.!The!study!found!that!over!the!one!year!period!following!the!earthquake,!9%!of!respondents!reported! that!a!member!of! their!household!had!been! raped!or!otherwise! forced! to!have! sex,!while!a!further!8%!had!been!the!victims!of!unwanted!touching.!Of!those!respondents!who!reported!the!gender!and! age! of! the! victim,! 12%! reported! the! victim! as! a! girl! and! 5%! as! a! boy.! SGBV! was! found! to! be!associated!with!food!insecurity,!and!some!women!and!girls!turned!to!“transactional!sex”!to!meet!their!basic!needs.66!The!absence!of!reliable!and!comprehensive!estimates!of!the!current!extent!of!risk!factors!and!outcomes!of!SGBV!against!children,!however,!inhibits!efforts!to!effectively!respond!to!the!needs!of!victims!and!evaluate!strategies!implemented!by!state!and!non`state!actors!to!address!postèarthquake!needs.!!!Street.children..Methodological! challenges! also! undermine! attempts! to! determine! the! number! of! children! in! and! of!Haiti’s!streets,!with!estimates!varying!markedly!over!the!past!decade!depending!on!source.!Prior!to!the!earthquake,! in! the! period! 2004`2009,! most! sources! referenced! UNICEF’s! estimate! of! 2,500! street!children!across!Haiti.67,68,69,70!Poverty!has!been!identified!as!a!primary!driver!of!the!prevalence!of!street!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!62!S.!Toupin,!Ensuring&haitian&women’s&participation&and&leadership&in&all&stages&of&national&relief&and&




65!K.!Tong!and!F.!Gaillardin,!Adolescent&sexual&and&reproductive&health&assessment&mission&to&PLAN,&Haiti!(July!2010).!

66!Center!for!Human!Rights!and!Global!Justice,!Sexual&violence&in&Haiti’s&IDP&camps:&Results&of&a&household&study,!New!York!University!School!of!Law!(March!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Child%20Protection/studies%20reseaches%20evaluation%20books/Haiti%20Sexual%20Violence%20March%202011.pdf!!

67!UNICEF!Executive!Board,!Revised&country&programme&document:&Haiti&(200952011)!(2009).!Available!at!http://www.unicef.org/about/execboard/files/Haiti`FRS2009`revised_feb2010Ènglish.pdf!!

68!UNICEF,!UNICEF&humanitarian&action&report&2008!(2008).!Available!at!http://www.unicef.org/har08/index_haiti.php!!

69!Amnesty!International,!Overcoming&poverty&and&abuse:&Protecting&girls&in&domestic&service&in&Haiti!(November!2009).!Available!at!http://www.amnesty.org/en/library/info/AMR36/004/2009!!

70!UN!ESC,!Situation!of!human!rights!in!Haiti,!UN!Doc.!E/CN.4/2005/123!(2006).!Available!at!http://ap.ohchr.org/documents/dpage_e.aspx?m=47!

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children,71,72!while!Kovats`Bernat!stated!in!2006!that!some!children!chose!to!live!in!the!street!because!it!provided! them! with! relatively! greater! freedom! and! economic! opportunity.73! Several! studies! have!suggested! that! a! significant! proportion! of! street! children! were! dismissed! or! runaway! indentured!servants!who!had!to!make!a! living!without! the!benefit!of! formal!education.74,75!Prior! to! January!2010,!most!street!children!were!migrants!from!the!provinces.!!!In! the!wake!of! the!earthquake,! it! is! likely! that!a! significantly!higher!proportion!of! street!children!now!include!urban!residents!whose!preèxisting!support!strategies!are!no! longer!adequate! for! their!needs.!The!2010!earthquake!undoubtedly!resulted!in!an!increase!in!the!number!of!street!children,!due!to!both!economic! necessity! stemming! from! the! loss! of! an! income`generating! family! member! and! the!destruction!of!residences.!However,!estimates!of!the!number!of!children!in!and!of!the!street!following!the!January!2010!earthquake!are!unavailable.!UNICEF!is!supporting!the!establishment!of!residential!care!facilities,!both!“overnight”!and!permanent,!to!provide!street!children!with!an!entry`point!to!services!and!support—although! demand! far! outstrips! supply.76! In! July! 2011,! President! Martelly! also! declared! his!intention! to! create! a! fund! to! support! programs! for! street! children! similar! to! the! National! Fund! for!Education,!though!further!details!have!not!been!released.77! !!Children!without!parental!care!are!always!among!the!most!vulnerable!in!society!due!to!the!absence!of!alternative!coping!strategies!and!social!support!networks!that!provide!an!adequate!substitute!for!family!care.! In!2006,! the!nationally! representative!Enquête!mortalité,!morbidité!et!utilisation!des! services! IV!(EMMUS! IV)! survey! found! that! 55%!of!Haitian! children!did!not! live! in! a! household!with!both!of! their!parents.! The! proportion! of! children! living! with! both! parents! was! higher! in! rural! areas! (47%)! than! in!urban!areas!(28%).!Countrywide,!roughly!25%!of!Haitian!children!lived!with!neither!parent!in!2006.!The!survey!also!determined!that!11%!of!all!Haitian!children!had!lost!at!least!one!parent,!and!that!1.3%!of!all!Haitian!children!had!no!surviving!parents.78,79,80,81!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!71!G.!R.!Smucker!and!G.!F.!Murray,!The&uses&of&children:&A&study&of&trafficking&in&Haitian&children,!USAID/Haiti!Mission!(December!2004).!Available!at!http://pdf.usaid.gov/pdf_docs/PNADF061.pdf!!

72!U.S.!Department!of!Labor,!Findings&on&the&worst&forms&of&child&labor:&2006&report:&Haiti!(2006).!Available!at!http://www.dol.gov/ilab/map/countries/haiti.htm!

73!J.!C.!Kovats`Bernat,!Sleeping&rough&in&Port5au5Prince:&An&ethnography&of&street&children&and&violence&in&Haiti!(Gainesville:!University!Press!of!Florida,!2006).!

74!G.!R.!Smucker!and!G.!F.!Murray,!The&uses&of&children:&A&study&of&trafficking&in&Haitian&children,!USAID/Haiti!Mission!(December!2004).!Available!at!http://pdf.usaid.gov/pdf_docs/PNADF061.pdf!!


76!UNICEF,!Residential&care&center&provides&a&refuge&for&street&children&in&Cap5Haitian!(February!2011).!Available!at!http://www.unicef.org/infobycountry/haiti_57670.html!!

77!HaitiLibre,!"Martelly!working!on!a!fund!project!for!street!children,"!HaitiLibre!(July!6,!2011).!Available!at!http://www.haitilibre.com/en/news`3116`haiti`social`martelly`workingònà`fund`project`for`street`children.html!



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!As! there!have!been!no!nationally! representative! surveys! assessing! children’s! living! situation! since! the!earthquake,! it!has!not!been!possible! to!derive!estimates! that!are!methodologically!comparable! to! the!set!of!EMMUS!surveys.!However,!the!perspective!is!widely!shared!that!the!proportion!of!children!living!in!households!with!only!one!or!neither!parent!has!increased,82!given!the!Haitian!Government’s!estimate!that! the! earthquake`related! death! of! more! than! 220,000! people! resulted! in! one! in! five! families! in!earthquake`affected! areas! experiencing! the! death! of! at! least! one! family! member.83! Additionally,! the!practice!of!placing!children!in!orphanages!as!a!response!to!poverty!rather!than!parental!death!was!likely!to!have!intensified!following!the!earthquake!due!to!the!destruction!of!families’!economic!opportunities!and! livelihood! strategies.! Similarly,! the! practice! of! sending! children! to! work! as! domestic! servants! to!support! their! own! and! their! family’s! needs!would! likely! have! increased.84! In!March! 2010,! the!Haitian!Government! stated! that! 103,000! cases! of! children!without! any! family! protection! had! been! identified!nationwide.85! However,! by! July! 2011,! UNCEF! stated! that! only! 8,212! separated! and! unaccompanied!children! had! been! registered! in! the! Child! Protection! sub`Cluster’s! family! reunification! and! tracking!database.86!It!is!unclear!what!proportions!of!children!in!both!the!Child!Protection!sub`Cluster’s!database!and! the! Haitian! Government’s! estimates! were! considered! separated! and! unaccompanied! minors,!orphans,!children!in!or!of!the!street,!or!living!in!a!single`parent!household,!though!the!exclusion!of!some!of!these!categories!from!the!sub`Cluster’s!database!may!contribute!to!the!apparent!disparity!between!its!coverage!and!the!Government’s!estimate!of!those!in!need.!!Poverty.Widespread! poverty! is! at! the! root! of! many! protection! challenges! facing! Haitian! children.! Despite! its!popularity! as! a! poverty! indicator,! relatively! few! nationally! representative! surveys! that! enumerate!headcount! poverty! proportions! (the! proportion! of! a! population! living! below! a! pre`defined! threshold!definition! of! “poor,”! rather! than! the! depth! of! poverty! experienced)! have! been! conducted! in! Haiti.!International! databases! cite! the! 2001! Haiti! Living! Conditions! Survey! (HLCS)! as! the! most! recent! and!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!80!M.!Justesen!and!D.!Verner,!Factors&impacting&youth&development&in&Haiti,!World!Bank!policy!research!working!paper!No.!4110!(2007).!Available!at!http://ddp`ext.worldbank.org/EdStats/HTIprwp07.pdf!!

81!Population!Council/UNFPA,!The&adolescent&experience&in5depth:&Using&data&to&identify&and&reach&the&most&

vulnerable&young&people:&Haiti&2005/06!(2009).!Available!at!http://www.unfpa.org/youth/docs/AdolescentDataGuide_Haiti2005`06.pdf!!


83!Government!of!Haiti,!Haiti&earthquake&PDNA:&Assessment&of&damage,&losses,&general&and&sectoral&needs!(March!2010).!Available!at!http://siteresources.worldbank.org/INTLAC/Resources/PDNA_Haiti`2010_Working_Document_EN.pdf!



86!Haiti!Child!Protection!Sub`Cluster,!Child&protection&sub5cluster&meeting&minutes:&28&July&2011!(July!2011).!Available!at!http://translate.google.com/translate?sl=auto&tl=en&js=n&prev=_t&hl=en&ie=UTF`8&layout=2&eotf=1&u=http%3A%2F%2Fhaiti.humanitarianresponse.info%2FPortals%2F0%2FChild%2520Protection%2FMinutes%2FCPSC_Meeting_Sept22.pdf!!

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reliable! estimate! of! poverty! nationwide,87,88,89,90! which! showed! that! 54.9%! of! the! Haitian! population!lived! on! less! than!US$1! per! day! in! 2001! (“absolute”! or! “extreme”! poverty;! US$1.25! in! 2005! dollars),!adjusted!for!purchasing!power!parity!(PPP).!It!was!also!estimated!that!72`76%!of!the!Haitian!population!in!2001! lived! in!“relative”!poverty,!or!below!US$2!per!day.!Poverty! is! strongly!correlated!with!area!of!residence,!with!“absolute”!or!“extreme”!poverty!found!to!be!more!than!twice!as!prevalent!(67%)!in!rural!areas!as!in!the!metropolitan!area!(23%);!other!urban!areas!were!between!these!two!extremes!(57%).!Of!rural! residents,!88%!were!estimated! to! live! in! relative!poverty,! compared! to!45%!of! those! in!Port`au`Prince,! and! 76%! in! other! urban! areas.91,92,93,94! Since! then,! (but! prior! to! the! 2010! earthquake)! the!percentage! of! people! living! in! absolute! and! relative! poverty! across! Haiti! was! estimated! to! have!decreased!to!47%!and!68%,!respectively.95!!!Income!inequality!is!also!pervasive!in!Haiti.!In!2010,!the!Haitian!government!stated!that!the!richest!10%!of!the!population!controlled!50%!of!all!revenue.96!Overabundance!of!unskilled!labor,!resulting!in!lower!wages,! high! unemployment,! and! low! intensity! of! economic! activity,! are! cited! as! key! determinants! of!Haiti’s!poverty!profile,!while! low!educational!attainment! is! the!strongest!predictor!of!poverty!status.97!On!the!eve!of!the!January!2010!earthquake,!most!Haitians!were!extremely!vulnerable!to!shocks!to!their!income.!In!this!same!study,!the!Haitian!government!highlighted!that!“most!Haitians!have!no!retirement!provision,!no!social!security!and!no!savings,”!so!that!inability!to!find!work!for!even!a!short!period!of!time!could! be! disastrous! for! the! financial! situation! of! the! household.98! In!March! 2010,! a! rapid! Emergency!Food! Security! Assessment! (EFSA)! conducted! by! the! Government! of! Haiti’s! National! Food! Security!Coordination! Unit! (Coordination& Nationale& de& la& Sécurité& Alimentaire! `! CNSA)! in! earthquake`affected!areas!found!that!48%!of!the!surveyed!population!was!poorer!as!a!result!of!the!earthquake,!with!a!higher!proportion! of! households! in! camps! reporting! being! poorer! after! the! earthquake! in! both! urban! (78%!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!87!World!Bank,!World&development&indicator&database.!Available!at!http://databank.worldbank.org/ddp/home.do?Step=12&id=4&CNO=2!

88!DevInfo,!MDG&database&2010:&Haiti.!Available!at!http://www.devinfo.info/mdginfo2010/!89!UNESCO,!Education&for&all&database:&Haiti.!Available!at!http://www.uis.unesco.org/ev.php?URL_ID=5262&URL_DO=DO_TOPIC&URL_SECTION=201!

90!UNICEF,!State&of&the&world’s&children&database.!Available!at!http://www.unicef.org/statistics/index_step1.php!91!World!Bank,!World&development&indicator&database.!Available!at!http://databank.worldbank.org/ddp/home.do?Step=12&id=4&CNO=2!


94!UNICEF,!State&of&the&world’s&children&database.!Available!at!http://www.unicef.org/statistics/index_step1.php!95!Government!of!Haiti,!Haiti&earthquake&PDNA:&Assessment&of&damage,&losses,&general&and&sectoral&needs!(March!2010).!Available!at!http://siteresources.worldbank.org/INTLAC/Resources/PDNA_Haiti`2010_Working_Document_EN.pdf!


97!D.!Verner,!Labor&markets&in&rural&and&urban&Haiti:&Based&on&the&first&household&survey&for&Haiti,!World!Bank!Sustainable!Development!Division!(March!2008).!Available!at!http://go.worldbank.org/MYDYDJHFS0!!


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were!poorer)!and!rural!areas!(70%!were!poorer)!than!the!average.99!Haitian!families’!ability!to!provide!for! their! children’s! rights! is! heavily! determined! by! their! access! to! financial! and! other! resources.! The!reduction! in! income!of! almost!half! of! households! in! earthquakeàffected!areas!has! compounded!preèxisting! endemic! poverty,! preventing!many! families! from! accessing! goods! and! services! necessary! for!their!children’s!safety!and!overall!development.!!Food.security..Prior!to!the!January!2010!earthquake,!Haiti!had!not!realized!its!constitutional!and!human!right!to!food,!with!much!of!its!population!instead!experiencing!chronic!mal`!and!under`nutrition.100!In!2007,!only!one!fifth! of! households! reported!being! able! to!meet! their! food!needs.! Food! consumption! is! highly! elastic!with! changes! in! income.! In!Haiti,! 32%!of!households!declared! that! increasing! their! food! consumption!would! be! their! first! priority! after! an! increase! in! income,!while!most! households! stated! that! reducing!food!consumption!is!their!primary!course!of!action!in!times!of!financial!strife.101!Thus,!unstable!income!sources,!lack!of!domestic!production,!low!purchasing!power,!and!the!absence!of!fallback!food!strategies!directly!contribute!to!the!nutritional!vulnerability!of!Haiti’s!children.!!!Following! the! 2010! earthquake,! surveyed!Haitians! identified! food! as! their! highest! priority.! The! Rapid!Emergency!Food!Security!Assessment!(EFSA)!found!that!31%!of!the!population!of!earthquakeàffected!areas! had! poor! or! borderline! food! consumption.! Differences! were! also! observed! between! those!displaced! as! a! result! of! the! earthquake! (43%)! and! those! who! were! not! displaced! (27%).102! Official!estimates! state! that! food! insecurity! in! earthquakeàffected! areas! increased! from! 40%! before! the!earthquake!to!52%!by!March!2010.103!In!large!IDP!camps,!this!figure!approximated!69%.104!!!Two!years!after!the!earthquake,!food!insecurity!remained!a!significant!concern.!According!to!a!national!food!security!survey!conducted!by!Food!Cluster!partners!in!the!second!half!of!2011,!4.5!million!Haitians,!or! almost! half! of! the! total! population,!was! food! insecure.105! In! response! to! the!poor! food! security! of!Haitian! children!and! their!high! levels!of!malnutrition,!UNICEF!and! its!partners!established! therapeutic!feeding! programs,! distributed! supplementary! food! and! infant! formula! for! pregnant! and! lactating!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!99!CNSA,!Rapid&post5earthquake&emergency&food&security&assessment:&Haiti!(March!2010).!Available!at!http://documents.wfp.org/stellent/groups/public/documents/ena/wfp221395.pdf!

100!Droits!et!Democratie/GRAMIR,!The&human&right&to&food&in&Haiti:&Report&of&an&international&fact5finding&mission!(2008).!Available!at!http://www.dd`rd.ca/site/publications/index.php?id=2316&subsection=catalogue!!

101!IMF,!Haiti:&Poverty&reduction&strategy&paper,!IMF!country!report!No.!08/115!(2008).!Available!at!http://www.imf.org/external/pubs/ft/scr/2008/cr08115.pdf!!

102!CNSA,!Rapid&post5earthquake&emergency&food&security&assessment:&Haiti!(March!2010).!!103!Government!of!Haiti,!Haiti&earthquake&PDNA:&Assessment&of&damage,&losses,&general&and&sectoral&needs!(March!2010).!Available!at!http://siteresources.worldbank.org/INTLAC/Resources/PDNA_Haiti`2010_Working_Document_EN.pdf!

104!UN!MINUSTAH,!Haiti:&6&months&after…!(July!2010).!Available!at!http://www.un.org/en/peacekeeping/missions/minustah/documents/6_months_after_commemoration.pdf!!

105!UN!OCHA,!Humanitarian&bulletin:&19&August&–&20&September&2011!(September!2011).!Available!at!http://haiti.humanitarianresponse.info/LinkClick.aspx?link=Nutrition+Cluster%2f19_Aout_20_Septembre_2011_Haiti+_Humanitarian_Bulletin+10+English.pdf&tabid=80&mid=1033!!

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women,! and! created! and! scaled! a! school! meal! program! soon! after! the! earthquake.106! In! the! period!between! September! 2010! and! August! 2011,! 14,128! children! had! been! admitted! to! 294! Outpatient!Feeding! Programs! (OTP),! 68,743! children!were! admitted! to! 369! Stabilization! Centers! (SC),! and! 2,061!children!had!been! admitted! to! Therapeutic! Feeding!Centers! (TFC).107! Performance! indicators! of! these!programs! and! centers! highlight! the! success! of! these! initiatives,! with! mortality! rates! below! Sphere!Standard!benchmark!thresholds!for!all!programs.108!!Water.and.sanitation.Access! to! safe! water! and! sanitation! facilities! are! key! risk! factors! for! the! protection! of! children! from!morbidity!and!mortality.!Chronically! low!access!both!before!and!after!the!2010!earthquake!has!placed!Haiti’s! children! at! significant! risk! of! water`borne! illness.! In! 2006,! 58%! of! Haiti’s! population! used!improved! drinking! water! sources,! again! with! significant! differences! between! urban! (70%)! and! rural!(51%)! areas.109,110,111! The! Haitian! Government! reported! that! access! to! clean! water! had! not! changed!appreciably!between!2006!and!January!2010.112!Most!water!in!Haiti!is!provided!by!small`scale!commerce!and!self`collection,!and!families!spend!a!significant!proportion!of!their!income!on!commercially!supplied!water.113!Additionally,!19.2%!of!respondents!in!a!2008!survey!stated!that!the!time!taken!to!collect!water!impacted!their!children’s!ability! to!attend!school.114!Following!the!2010!earthquake,!Water,!Sanitation!and!Hygiene! (WASH)!Cluster!partners!established!a! substantial!water!distribution! system! to!meet! the!needs!of!the!earthquakeàffected!population.!By!July!2010,!1.2!million!people!were!receiving!at!least!5!liters!per!day! from!Cluster!partners.115!Recently,! the!WASH!Cluster!has!begun!disengaging! from!water!delivery! activities,! transitioning! to! system! strengthening! initiatives.116! However,! as! only! 39%! of! IDP!camps! had! access! to! chlorinated!water! points! in!May! 2011,! the! provision! of! clean!water! remains! an!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!106!UN!MINUSTAH,!Haiti:&6&months&after…!(July!2010).!Available!at!http://www.un.org/en/peacekeeping/missions/minustah/documents/6_months_after_commemoration.pdf!!

107!Haiti!Nutrition!Cluster,!Nutrition&cluster&update:&Issue&3!(October!2011).!Available!at!http://haiti.humanitarianresponse.info/LinkClick.aspx?link=English+Nutrition+cluster+update+issue+3.pdf&tabid=80&mid=1631!!

108!Sphere!Project,!“3.!Management!of!acute!malnutrition!and!micronutrient!deficiencies,”!in!Sphere!Project,!Humanitarian&charter&and&minimum&standards&in&humanitarian&response!(2011).!Available!at!http://www.spherehandbook.org/en/3`managementòfàcute`malnutritionànd`micronutrient`deficiencies/!

109!DevInfo,!MDG&database&2010:&Haiti.!Available!at!http://www.devinfo.info/mdginfo2010/!110!Population!Reference!Bureau,!PRB&datafinder:&Haiti.!Available!at!http://www.prb.org/datafinder.aspx!111!World!Bank,!World&development&indicator&database.!Available!at!http://databank.worldbank.org/ddp/home.do?Step=12&id=4&CNO=2!


113!CNSA,!Rapid&post5earthquake&emergency&food&security&assessment:&Haiti!(March!2010).!Available!at!http://documents.wfp.org/stellent/groups/public/documents/ena/wfp221395.pdf!

114!M.!K.!Varma,!M.!L.!Satterthwaite,!A.!M.!Klasing,!et!al.,!“Woch!nan!soley:!The!denial!of!the!right!to!water!in!Haiti,”!Health&and&Human&Rights!10/2!(2008),!pp.!67`89.!


116!Government!of!Haiti/ACF,!Strategie&de&desengagement:&Water&trucking!(March!29,!2011).!Available!at!http://www.dinepa.gouv.ht/wash_cluster/index.php?option=com_rokdownloads&view=file&task=download&id=1492%3A201103desengagementwt`dinepaàcfstrategievf&Itemid=67!

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urgent! need.117! UNICEF! has! prioritized! the! provision! of! clean! water! in! schools,! and! by! January! 2011!reported!reaching!150!schools!with!comprehensive!water,!sanitation,!and!hygiene!packages.118!!Lack! of! access! to! sanitation! also! remains! a! pressing! concern.! In! 2008,! only! 17%! of! Haitians! used!improved! sanitation! facilities,! exhibiting! differences! between! urban! (24`29%)! and! rural! (12%)!areas.119,120,121!Lack!of!access! to!appropriate!sanitation! facilities! in!both!public!and!private!schools!was!also! a! concern,! given! its! potential! to! dissuade! enrollment.122! Expanding! access! to! sanitation! was!identified!as!a!key!priority! following! the!earthquake.!By! July!2010,! the!WASH!Cluster!had!constructed!11,000! toilets,! resulting! in! an! average! toilet`to`person! ratio! of! approximately! 1! to! 145! and! reaching!roughly!1.6!million!people.123!By!May!2011,!a!survey!by!the!WASH!Cluster!found!that!94%!of!surveyed!IDP!camps!with!more!than!1,500!people!had!a!ratio!of!less!than!1!to!100!per!latrine.124!This!proportion!represents! a! significant! improvement! during! the! first! five! months! of! 2011,! although! significant! gaps!were!identified!among!Communes.!Troublingly,!only!18%!of!surveyed!IDP!camps!had!functioning!hand!washing!stations!in!May/June!2011.125!!Healthcare.Before! the! earthquake,! Haitians! suffered! from! a! chronic! lack! of! access! to! healthcare! services! due! to!prohibitive!cost,!absolute!lack!of!healthcare!infrastructure!and!unequal!distribution!across!the!country,!a!shortage! of! trained! professionals,! and! a! culture! that! places! the! responsibility! for! the! health! of!many!women! in! the! hands! of! their! husbands.! On! the! eve! of! the! earthquake,! the! UN! Office! for! the!Coordination!of!Humanitarian!Affairs!(UN!OCHA)!estimated!that!44%!of!Haitians!lacked!access!to!health!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!117!UN!OCHA,!Humanitarian&bulletin:&1&July&–&25&July&2011!(July!2011).!Available!at!http://haiti.humanitarianresponse.info/LinkClick.aspx?link=Nutrition+Cluster%2f1_Juillet_25Juillet2011_Haiti_Humanitarian_Bulletin.pdf&tabid=80&mid=1033!!

118!UNICEF,!Children&in&Haiti:&One&year&after&–&the&long&road&from&relief&to&recovery!(January!2011).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/10CF91515919332F49257811001C26F3`Full_Report.pdf!!

119!Millennium!Project,!Countdown&to&2015:&2010&Country&profiles:&Haiti!(2010).!Available!at!http://www.countdown2015mnch.org/documents/2010report/Profile`Haiti.pdf!!


121!Oxfam!America,!Aid&to&Haiti,&6&months&on:&a&long&way&to&go,!Oxfam!media!briefing!(July!2010).!Available!at!http://www.oxfamamerica.org/publications/aid`to`haiti`6`monthsònà`long`way`to`go/!!



124!Haiti!WASH!Cluster,!Enquete&WASH&dans&les&Sites&d’hebergement&temporaire!(May!2011).!Available!at!http://www.dinepa.gouv.ht/wash_cluster/index.php?option=com_rokdownloads&view=file&Itemid=57&id=1468:110616ènquete`wash`site`hebergement`temporaire!!

125!UN!OCHA,!Humanitarian&bulletin:&1&July&–&25&July&2011!(July!2011).!Available!at!http://haiti.humanitarianresponse.info/LinkClick.aspx?link=Nutrition+Cluster%2f1_Juillet_25Juillet2011_Haiti_Humanitarian_Bulletin.pdf&tabid=80&mid=1033!!

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services!as!a!result!of!prohibitive!costs.126!Using!similar!methods,!the!World!Food!Programme!estimated!the!gap!in!access!at!47%!of!the!population.127!!!As! is! occasionally! the! case! in!massive! humanitarian! relief! efforts,! access! to! basic! healthcare! actually!improved!for!many!Haitians!following!the!earthquake,!due!to!the!large!influx!of!medically!oriented!relief!organizations.! A! study! by! the!MIT! Lincoln! Laboratory! and!Harvard!Medical! School! found! that! 80%! of!respondents! in!Portàu`Prince!were!able!to!travel!to!medical! facilities! in! less!than!ten!minutes! in!April!2010,128!while!Schiff!et&al.!found!that!the!majority!of!IDPs!nationwide!could!travel!to!health!services!in!less! than! thirty!minutes.129! There! remains! the! longer`term!need! to!build! local! capacity! to! sustain! this!short`term!improvement!in!access,!since!30!of!the!49!hospitals!operating!in!earthquakeàffected!areas!prior!to!the!earthquake!were!either!damaged!or!destroyed,!and!numerous!health!sector!workers!were!killed.130!!Communicable! diseases! drive! childhood!mortality! in!Haiti.! According! to! PAHO,! tuberculosis,! diarrheal!diseases,! malnutrition,! HIV/AIDS,! and! malaria! were! the! five! leading! causes! of! death! in! 2007.131! In!contrast,!the!WHO!Global!Health!Observatory!database!states!that!the!five!leading!causes!of!under`five!death! in! 2008! were! pneumonia! (22%),! diarrhea! (22%),! prematurity! (10%),! birth! asphyxia! (9%),! and!neonatal! sepsis! (5%),! with! “other! causes”! accounting! for! 24%! of! deaths! in! this! age! group.132!Discrepancies!between!these!estimates!may!be!explained!by!the!exclusion!of!neonatal!and!infant!causes!of!death!by!PAHO.!Similar!to!the!under`five!age!group,!PAHO!stated!in!2007!that!tuberculosis,!diarrheal!disease,!malnutrition,!HIV/AIDS,!and!malaria!were!the!leading!causes!of!death!of!children!aged!5`9,!but!that!non`communicable! causes,! such! as! violence! and!accidents,!were! responsible! for! 8%!of! deaths! in!this! age! group.! The!mortality! profile! of! adolescent!Haitians! (10`19)! differs! from! that! of! their! younger!peers,!as!non`communicable!causes!play!an! increasingly! important!role.! In!2007!PAHO!stated!that!the!six! leading! causes! of! death! among! this! age! group! were! HIV/AIDS,! physical! assault,! accidents,!tuberculosis,!typhoid,!and!pregnancy`related!factors!(maternal!mortality).133!!!Low!water,! sanitation,! and! hygiene! coverage! both! before! and! after! the! 2010! earthquake! also! led! to!significant! risks!of!water`borne!diseases.! In!2006,! the!EMMUS! IV!survey! found! that!24%!of!under`five!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!126!UN!OCHA!Haiti,!Haiti&before&January&12th,!Internal!document!(2010).!Available!at!http://ochaonline.un.org/OchaLinkClick.aspx?link=ocha&docId=1165439!!

127!Cited!in!Oxfam!America,!Aid&to&Haiti,&6&months&on:&a&long&way&to&go,!Oxfam!media!briefing!(July!2010).!Available!at!http://www.oxfamamerica.org/publications/aid`to`haiti`6`monthsònà`long`way`to`go/!

128!UN!OCHA!Haiti,!Haiti:&Humanitarian&assessment&key&findings&No.&4&(April!2010).!129!L.!Ivers,!A.!Schiff,!D.!Jones,!et!al.,!“Assessment!and!analysis!of!Haitian!HADR!data”!(presentation!to!the!Haiti!Assessments!Working!Group,!April!27!2010).!



132!WHO,!Global&health&observatory&database:&Haiti.!Available!at!http://www.who.int/gho/en/!133!PAHO,!Health&in&the&Americas&2007:&Volume&II&–&countries:&Haiti!(2007).!Available!at!http://www.paho.org/hia/archivosvol2/paisesing/Haiti%20English.pdf!!

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Haitian!children!had!diarrhea! in! the! two!weeks!preceding! the!survey,! but! that!only!47%!of!under`five!children!received!either!a!packet!mixture!or!similarly!prepared!oral!rehydration!therapy!solution!the!last!time! they!had!diarrhea.134! In!2008,!diarrheal!disease!accounted! for!22%!of!all! under`five!deaths.135! In!2006,! the! EMMUS! IV! survey! found! that! 40%!of! under`five! children! had!displayed! symptoms!of! acute!respiratory!infection!(ARI)!in!the!two!weeks!preceding!the!survey,136!but!that!few!children!displaying!ARI!symptoms!were!taken!to!a!health!facility!for!assistance.!PAHO!stated!that!in!2006!only!20%!of!under`five!children! displaying! ARI! symptoms! had! been! examined! to! obtain! treatment,137! while! the!WHO!Global!Health!Observatory!and!Measure!DHS!databases!state!that!31.5%!of!under`five!children!displaying!ARI!symptoms!had!been! taken! to!a!health! facility! in!2006.138! The! source!of! this!discrepancy! is!unclear,! as!these! sources! all! cite! EMMUS! IV! survey!data.! In! 2008,! 22%!of! under`five! deaths!were! attributable! to!pneumonia.139!While! injuries! were! the! primary! health! concern! of! children! immediately! following! the!earthquake,!accounting! for!an!estimated!56%!of!deaths!among!children!under! five! in!2010,140!UNICEF!has! noted! that! children’s! risk! profile! had! reverted! to! previous! patterns! after! approximately! three!months.141!

!Despite! efforts! to! expand! access! to! clean!water,! sanitation,! and! hygiene! following! the! earthquake,! a!cholera!outbreak!was!identified!in!October!2010!in!Artibonite,!in!central!Haiti.142!By!April!2011,!274,418!cases!and!4,787!deaths!had!been!identified!across!all!Departments.143!In!August!2011,!the!Health!Cluster!reported! that! the!number!of! identified! cholera! cases! had! reached!419,511!by! 31! July! 2011,! of!which!222,359! had! been! hospitalized! and! 5,968! had! died,! but! that! case! fatality! rates! and! new! cases! were!slowing!in!most!Departments.144!By!1!January!2012,!the!Haitian!Ministry!of!Public!Health!and!Population!(Le&Ministère&de&la&Santé&Publique&et&de&la&Population!–!MSPP)!reported!that!458,216!cholera!cases!had!been! identified! since! the! beginning! of! the! epidemic,!with! a! global! case! fatality! rate! of! approximately!1.4%.145! Analysis! of!MSPP! data! indicates! that! 12.6%! of! all! cholera! cases! identified! by! 1! January! 2012!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!134!PAHO,!Health&in&the&Americas&2007:&Volume&II&–&countries:&Haiti!(2007).!Available!at!http://www.paho.org/hia/archivosvol2/paisesing/Haiti%20English.pdf!!

135!WHO,!Global&health&observatory&database:&Haiti.!Available!at!http://www.who.int/gho/en/!136!PAHO,!Health&situation&in&Haiti&before&the&2010&earthquake,!Presentation!at!Haiti!Health!Cluster!(January!2010).!Available!at!http://ec.europa.eu/echo/files/aid/countries/Haiti_paper_01102010.pdf!!


138!WHO,!Global&health&observatory&database:&Haiti.!Available!at!http://www.who.int/gho/en/!139!WHO,!Global&health&observatory&database:&Haiti.!Available!at!http://www.who.int/gho/en/!140!WHO,!Global&health&observatory&database:&Haiti.!Available!at!http://www.who.int/gho/en/!141!UNICEF,!Children&of&Haiti:&Progress,&gaps&and&plans&in&humanitarian&action!(April!2010).!Available!at!http://www.unicef.org/romania/FINAL_UNICEF_Haiti_90`Day_Report_13_April_2010_FINAL.pdf!!

142!D.!Walton,!A.!Suri,!and!P.!Farmer,!“Cholera!in!Haiti:!Fully!integrating!prevention!and!care,”!Annals&of&Internal&Medicine!154/9!(2011),!pp.!635`637.!

143!Haiti!Health!Cluster,!Health&cluster&bulletin&23:&Cholera&and&post5earthquake&response&in&Haiti!(April!2011).!Available!at!http://new.paho.org/disasters/index.php?option=com_docman&task=doc_download&gid=1750!!

144!Haiti!Health!Cluster,!Health&cluster&bulletin&27:&Cholera&and&post5earthquake&response&in&Haiti!(August!2011).!Available!at!http://new.paho.org/disasters/index.php?option=com_docman&task=doc_download&gid=1850!

145!MSPP,!Rapports&journaliers&du&MSPP&sur&l'évolution&du&choléra&en&Haiti&(MSPP&daily&reports&on&the&evolution&of&

cholera&in&Haiti)!(1!January!2012).!Available!at!

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were! among! children! under! age! 5—approximately! proportional! to! their! share! of! the! total! Haitian!population—but!that!the!global!case!fatality!rate!for!this!age!group!(0.8)!was!almost!half!of!that!for!all!other!age!groups!combined!(1.4%).146!!Sexual.and.Reproductive.Health.Reproductive! health! risk! factors! and! outcomes! carry! serious! consequences! for! children! and! their!mothers!in!Haiti.!Available!data!indicate!that!programs!and!policies!undertaken!to!improve!reproductive!health!in!Haiti!over!the!past!two!decades!have!seen!positive!results,!although!issues!including!unwanted!pregnancy,! maternal! mortality,! and! low! rates! of! professionally! assisted! delivery! have! persisted.147!Estimates!of!Haiti’s!Maternal!Mortality!Ratio!are!high,!but!different!sources!vary!significantly.! In!2008,!the!Haitian!Government!reported!a!MMR!of!630,148!while!UNICEF!models!estimated!that!Haiti’s!MMR!was! 300! maternal! deaths! per! 100,000! live! births.149! According! to! the! Population! Reference! Bureau,!women! in!Haiti! had! a! 1! in! 93!probability! of! dying! from!maternity`related! causes! in! 2008.150! The!high!prevalence! of! adolescent! pregnancy! in! Haiti! is! of! particular! concern,! as! adolescent!mothers! younger!than!15!are!five!times!more!likely!to!die!during!childbirth!than!are!women!in!their!twenties.151!Data!for!maternal!mortality!in!the!post`earthquake!period!remain!unavailable.!!Significant!discrepancies!exist!in!estimates!of!adolescent!Haitians’!fertility,!although!all!sources!indicate!a!reduction!over!the!past!decade.!The!World!Bank!estimated!an!adolescent!fertility!rate!of!44.3!births!per!1,000!women!aged!15`19!in!2009,152!while!the!PAHO!estimate!of!69!births!per!1,000!women!aged!15`19!in!2005/2006!suggests!higher!prevalence!of!early!pregnancy.153!High!adolescent!fertility!in!Haiti!is!driven!by!early!onset!of!sexual!activity,!early!marriage,!and!low!contraceptive!use,!with!53%!of!Haitian!girls!reporting!having!had!sex!before!age!18,154!29.9%!of!females!married!before!their!18th!birthday,155!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!http://mspp.gouv.ht/site/download.php?file=downloads/Rapport%20journalier%20MSPP%20du%2001%20janvier%202012.pdf!&


cholera&in&Haiti)!(1!January!2012).!Available!at!http://mspp.gouv.ht/site/download.php?file=downloads/Rapport%20journalier%20MSPP%20du%2001%20janvier%202012.pdf!


148!UNICEF,!State&of&the&world’s&children&2007!(Oxford:!Oxford!University!Press,!2007).!Available!at!http://www.unicef.org/sowc/!!


150!Population!Reference!Bureau,!PRB&datafinder:&Haiti.!Available!at!http://www.prb.org/datafinder.aspx!151!UNICEF,!Progress&for&children&number&7:&A&report&card&on&maternal&mortality!(September!2008).!Available!at!http://www.unicef.org/progressforchildren/files/Progress_for_Children`No._7_Lo`Res_082008.pdf!!



154!Institut!Haitien!de!l’Enfance,!HIV/AIDS&in&Haiti:&Key&findings&of&the&mortality,&morbidity,&and&utilization&of&

services&survey!(2006).!Available!at!http://www.measuredhs.com/pubs/pub_details.cfm?id=767&srchTp=home!

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and! only! 20%! of! female! youth! age! 15`24! reporting! condom!use! during! the! last! time! they! had! sex! in!2006.156! All! three! outcomes! were! associated! with! poverty,! rural! living! status,! and! lack! of! education.!Unconfirmed! findings! indicate! a! sharp! increase! in! adolescent! pregnancies! in! IDP! camps! following! the!earthquake,157!while!other!sources!highlight!the!use!of!“transactional!sex”!by!Haitian!girls!and!women!to!obtain!basic!goods!and!services,158!further!exacerbating!sexual!and!reproductive!health!risks.!!The!high!rate!of!adolescent!pregnancy!in!Haiti!is!pertinent!because!there!is!significantly!lower!access!to!skilled!delivery! services! for!adolescents! in! rural! areas! compared! to!urban!areas,! and! large!differences!among! Departments.! Overall,! approximately! 33%! of! births! among! girls! age! 15`24!were! assisted! by! a!health!professional!(50%!in!urban!areas!versus!25%!in!rural!areas),!while!a!further!31%!were!assisted!by!a!trained!birth!attendant!(28%!in!urban!areas!versus!33%!in!rural!areas).159!Tong!et&al.&note!that!since!the!January!2010!earthquake,!safe!delivery!services,!as!well!as!antenatal!and!postnatal!care,!have!been!provided! for! free!by!public! and! international! response!health! facilities,! resulting! in! improved! rates! of!medically!supervised!deliveries.160!However,! the!recent!reduction! in! the!number!of!NGOs!operating! in!Haiti,! as! well! as! the! concentration! of! relief! efforts! in! the! Portàu`Prince! metropolitan! area,! raise!concerns!regarding!both!the!sustainability!and!equity!of!this!increase!in!delivery!supervision.!!!Sexual!health!is!of!particular!concern!for!Haitian!adolescents.161!Early!sexual!debut,!multiple!concurrent!partnerships,! and! low! rates! of! condom! use! place! young! Haitians! at! heightened! risk! for! sexually!transmitted!diseases! (STDs).!Many!Haitian!girls!experience!greater! vulnerability! to!STDs!due! to! sexual!violence!and!age!disparities!with!older!partners.162!Haiti!has!the!highest!HIV!prevalence!of!any!country!in!the! Western! Hemisphere,163! and! high! levels! of! knowledge! about! HIV! and! other! STDs! have! failed! to!translate! into! effective! preventative! behavior! for! most! adolescent! Haitians.! HIV! prevalence! among!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!155!Population!Council/UNFPA,!The&adolescent&experience&in5depth:&Using&data&to&identify&and&reach&the&most&




157!K.!Calvin,!Lighting&the&future&for&Haiti’s&women,!UN!Foundation!(January!2011).!Available!at!http://www.unfoundation.org/who`weàre/impact/ourìmpact/empowering`women`girls/lighting`the`future.html!!

158!IFRC,!Haiti&recovery&assessment:&Volume&1&–&Synthesis&report!(March!2010).!Available!at!http://haiti.humanitarianresponse.info/LinkClick.aspx?fileticket=jNS41RGePVg%3d&tabid=149&mid=1043!!






services&survey!(2006).!Available!at!http://www.measuredhs.com/pubs/pub_details.cfm?id=767&srchTp=home!163!M.!Loudon,!A&study&of&integrated&interventions&for&children&made&vulnerable&by&HIV/AIDS&in&Haiti:&A&case&study&

of&La&Maison&l’Arc5en5Ciel,!UNAIDS/UNICEF!(2006).!Available!at!http://www.unicef.org/lac/Haiti_Case_Study`Children_made_Vulnerable_by_AIDS(1).pdf!!

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Haitian! youth! (15`24! years)! was! higher! than! in! children! 0`14,! with! an! estimated! prevalence! of! 0.6%!among!males! and! 1.4%! among! females! in! this! age! group! in! 2007.164! By! 2009,! the! prevalence! of! HIV!among!female!youth!had!dropped!by!a! tenth!of!a!percent!according!to!the!World!Bank,!although!HIV!prevalence! among! male! youth! remained! constant.165! The! disparity! between! male! and! female! HIV!prevalence! in! this! age! group! supports! the! argument! that! large! age! differences! between! partners!negatively!affect!the!younger!females,!as!the!older!partners!of!these!young!women!are!more!likely!to!be!HIV`positive!than!men!of!the!same!or!younger!age!as!their!female!partners.!Estimates!of!HIV!prevalence!among!Haitian!children!vary!by!source.!UNICEF!reported!that!in!2007!there!were!approximately!19,000!children! living!with!HIV,166! in! contrast! to! the!World! Bank’s! estimate! of! 13,000.! The!World! Bank! later!estimated!that!by!2009,!the!number!of!children!under!age!15!living!with!HIV!had!fallen!to!approximately!12,000.167!!.Mental.health.Very! little! data! exist! on! the! prevalence! of! mental! health! difficulties! in! Haiti.! This! report! found! no!quantitative! studies! on! the! mental! and! psychosocial! health! of! children.! However,! as! part! of! their!submission! to! the! Haitian! Government’s! Post`Disaster! Needs! Assessment! following! the! 2010!earthquake,!Plan!International!conducted!a!survey!during!January!and!February!of!2010!that!shed!light!on! the! psychosocial! needs! of! Haiti’s! children! and! youth.! This! analysis! revealed! significant! lingering!psychosocial! health! issues! stemming! from! the! earthquake.! Haitian! children! who! had! witnessed! the!death,! injury,! and/or! disability! of! close! family!members! and! friends,! or! had! been! injured! or! disabled!themselves,! listed! psychological! trauma,! grief,! sleeplessness,! and! fear! as! serious! concerns.168! Other!studies!also!noted!that!the!climate!of!insecurity!after!the!earthquake!had!exacerbated!the!likelihood!of!poor!mental!wellbeing.169!Children!are!inherently!more!at!risk!in!the!short!and!long!term!as!they!are!still!physically,! mentally,! and! emotionally! developing.170! Those! suffering! from! mental! and! psychosocial!concerns!also!have!few!avenues!to!access!support!and!services!in!Haiti.!Before!the!earthquake,!only!two!public! mental! health! facilities! were! available! in! Haiti,! and! both! were! situated! in! Port`au`Prince.!According! to! PAHO,! while! a! number! of! small,! private! centers! have! opened! outside! the! capital,! the!demand!for!mental!and!psychosocial!health!services!far!exceeds!supply.171!To!appropriately!provide!for!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!164!WHO,!Epidemiological&fact&sheet&on&HIV&and&AIDS:&Haiti!(December!2008).!Available!at!http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_HT.pdf!!


166!UNICEF,!UNICEF&humanitarian&action&report&2007!(2007).!Available!at!http://www.unicef.org/har07/index_37587.htm!!


168!E.!Lacroi,!Anticipating&the&future:&Children&and&young&people’s&voices&in&Haiti’s&post5disaster&needs&assessment,!Plan!International!(March!2010).!Available!at!http://plan`international.org/files/global/haiti`pdna`report.pdf!!


170!World!Vision,!Rapid&assessment&report:&Haiti&earthquake&response!(March!2010).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/Full_Report_583.pdf!!


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Haitian! children’s! long`term! psychosocial! health,! sustainable! systems! of! mental! health! care! are!essential.!!Education.Education!in!Haiti!is!characterized!by!low!quality,!the!existence!of!significant!barriers!to!enrollment,!low!enrollment! rates,!delayed!entry,!high!proportions!of! repeating!and!over`age!students,!and!substantial!early! dropout! rates.! At! age! three,! Haitian! children! are! eligible! for! early! childhood! education! that!officially!last!for!three!years.172!Due!to!competition!for!limited!spaces,!completion!of!pre`school!is!often!used!as!a!screening!tool! for!admittance!to!primary!school.! In!2009,!however,! the!Haitian!Government!stated!that!only!5.5%!of!pre`schools!were!publicly!supported,!thus!serving!only!4.67%!of!Haiti’s!595,000!preschoolers.173! Private! schools! are! generally! located! in! urban! areas,! prohibiting! access! for! the!many!Haitians!living!far!from!these!centers.174!As!such,!many!children!are!disenfranchised!from!the!beginning!of!their!engagement!with!the!education!system.!!!Haitian! children! are! legally! able! to! enter! primary! school! at! age! six.! Primary! education! is! compulsory!(though!unenforced)!and!divided!into!nine!years,!while!non`compulsory!secondary!education!comprises!a!further!four!years.175!UNICEF!reports!that!there!were!approximately!22,000!schools!in!Haiti!prior!to!the!January!2010!earthquake.176!The!increase!in!the!number!of!schools!over!the!past!thirty!years!has!largely!been! attributable! to! the! establishment! of! private! schools! that! operate! outside! of! government!regulation.!Additionally,! these!private! schools! generally! teach!only! the! first! cycle! (years! 1! through!4),!requiring!students!to!change!schools!in!order!to!continue!their!education.177!On!the!eve!of!the!January!2010!earthquake,!only!8%!(1,241)!of!all!primary!and!secondary!schools!in!Haiti!were!state!schools,!while!the!remaining!92%!(14,027)!were!privately!operated.!As!a!result,!approximately!80%!(1,716,187)!of!all!students!in!Haiti!(2,106,805)!were!educated!in!fee`based!non`public!schools.178,179,180!As!many!as!23%!of!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!172!Haitian!Ministry!of!Education,!Youth!and!Sports,!The&problem&of&over5age&students&in&the&Haitian&education&

system:&An&overview.!UNESCO!Education!for!all!in!the!Carribbean:!Assessment!2000!monograph!series!18!(2000).!Available!at!http://unesdoc.unesco.org/images/0013/001364/136433e.pdf!

173!Government!of!Haiti,!2009&national&policy&framework&for&an&integrated&approach&to&early&childhood&

development!(January!2009).!174!UNESCO,!Haiti:&Early&childhood&care&and&education&(ECCE)&programmes,!UN!Doc.!IBE/2006/EFA/GMR/CP/36!(2006).!Available!at!http://unesdoc.unesco.org/images/0014/001480/148026e.pdf!!

175!Haitian!Ministry!of!Education,!Youth!and!Sports,!The&problem&of&over5age&students&in&the&Haitian&education&



177!B.!Hadjadj,!Education&for&all&in&Haiti&over&the&last&20&years:&Assessment&and&perspectives,!UNESCO!Education!for!all!in!the!caribbean:!Assessment!2000!monograph!series!No.!18!(2000).!Available!at!http://unesdoc.unesco.org/images/0013/001363/136393e.pdf!!

178!Haiti!Education!Cluster,!Education&cluster&bulletin:&18&February&2010!(February!2010).!Available!at!http://oneresponse.info/Disasters/Haiti/Education/Documents/ECU!English.docx!!


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all!schools!in!Haiti!were!damaged!or!destroyed!by!the!earthquake,!including!80`90%!of!all!schools!in!the!earthquakeàffected! areas.181,182! Although! they! were! closed! in! the! aftermath! of! the! earthquake,! the!majority!of!structurally!sound!schools!reopened!by!December!2010.183!!While!84%!of!children!age!6`17!were!attending!school!in!2006,!most!of!those!children!were!not!enrolled!in! the! correct! year! for! their! age.184! In! 2007,! the! Haitian! Government! estimated! the! country’s! gross!enrollment! ratio! for! the! first! six! years! of! basic! (primary)! education! at! 136%,& indicating! that! many!students! who! were! not! of! the! official! age! for! these! grades! were! enrolled! in! those! years.! In! stark!contrast,!the!combined!GER!of!Haiti’s!3rd!primary!cycle!(grades!7`9)!and!secondary!education!(grades!10`13)!was!estimated!at!46.2%,! indicating!that! the!total!number!of!students!of!any!age!enrolled! in!these!grades! was! less! than! half! of! the! 12`18! yearòld! population.185! According! to! Government! estimates,!Haiti’s!basic!and! secondary!education!net!enrollment! ratios! (NER)!were!76%!and!22%,186! respectively,!although!some!sources!place!the!basic!education!NER!as! low!as!50%.187!Discrepancies!between!Haiti’s!gross!and!net!enrollment!ratios!support!the!conclusion!that!the!Haitian!education!system!is!inefficient,!highlighting!the!impact!of!late!entry!and!grade!repetition!on!the!presence!of!overàge!students.188!!!Nationally! representative!data!on!postèarthquake! school!attendance!did!not!exist! at! the! time!of! this!writing,!but!data!collected!as!part!of!the!IDP!Site!Registration!system!indicate!that!children!living!in!IDP!camps!may!now!have!greater!education!utilization!than!a!number!of!preèarthquake!estimates.!Across!the! 189! camps! registered! as! part! of! the! second! phase! of! the! Haitian! government! and! International!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!180!H.!D.!Nielsen,!Moving&towards&free&primary&education:&Policy&issues&and&implementation&challenges&5&A&state&of&

the&art&review,!UNICEF!social!and!economic!policy!working!paper!(2009).!Available!at!http://www.unicef.org/socialpolicy/index_52077.html!!


182!UNICEF,!UNICEF&rebuilds&education&in&Haiti&from&the&ruins!(January!2011).!Available!at!http://www.unicef.org/malaysia/media_news11ùnicef`rebuildsèducationìn`haiti`from`the`ruins.html!!

183!Haiti!Education!Cluster,!Education&cluster&situation&report:&14&December&2010!(December!2010).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/reports/Education_Cluster_SitRep_14_12_2010.pdf!!



185!Cited!in!L.!Wolff,!Education&in&Haiti:&The&way&forward,!Partnership!for!Educational!Revitalization!in!the!Americas!(PREAL)!(September!2008).!Available!at!http://www.thedialogue.org/PublicationFiles/Education%20in%20Haiti%20`%20The%20Way%20Forward%20`%20FINAL%20`%209`15`08.pdf!!





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Organization! for! Migration’s! IDP! registration! process,! 77%! children! aged! 6`14! were! found! to! be!attending!school!(77.1%!of!boys!and!76.9%!of!girls).189!!Despite! their! constitutional! right! to! free!basic! education! (grades!1`6),!Haitian! children! face! significant!barriers! to! school! enrollment.! Unavailability! of! school! spaces,! the! cost! of! school! fees,! uniforms,! and!learning!materials,!and!children’s!rural!status!prevent!many!from!attending!school,!while!some!families!question! whether! the! low! quality! of! education! warrants! the! significant! financial! investment.190! The!Haitian! Government! has! identified! education! sector! reform! as! a! priority! in! the! postèarthquake!period.191! In!September!2011,!President!Martelly!officially! launched!the!Free!Education!Programme!to!expand!access!to!education.!The!Programme!aims!to!provide!free!education!to!142,000!children!aged!6`12!who!have!not!previously!attended!school.!Additionally,!200,000!children!in!grades!1!through!6!from!poor! neighborhoods! will! receive! a! grant! to! cover! education! expenses.192! The! Programme! is! to! be!supported! by! the! National! Fund! for! Education! (FNE),! established! in!May! 2011,! which! is! funded! by! a!US$0.05!per!minute!surcharge!on! international! calls!and!a!US$1.50!surcharge!on! international!money!transfers.!It!was!estimated!that!the!fund!would!collect!US$8.5!per!month!following!its!implementation!in!June.!However,!after!seven!months!of!operation,!the!Haitian!Senate!Economy!and!Finance!Committee!was! informed! that! the! Fund’s! account! held! only! US$4.8! million! of! the! expected! US$55! million! that!should!have!been!collected!to!that!point,193!while!the!Minister!of!Education!stated! in!November!2011!that! the!FNE!was!not!operational!because! it! lacked!a! legal! framework.194!More! recent! information!on!the!operational!status!of! the!FNE!and!the!Free!Education!Programme!were!unavailable!at! the!time!of!writing.! However,! if! operationalized,! it! is! hoped! that! this! initiative,! in! combination! with! school!construction!and!learning!material!distribution!projects,!will!significantly!improve!young!Haitians’!access!to!education!in!the!future.!...

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!189!Haiti!Education!Cluster,!Education&cluster&bulletin:&8&August&2011!(August!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/reports/Aout%202011/Education_Cluster_SitRep_080811.pdf!!

190!H.!Lunde,!Youth&and&education&in&Haiti:&Disincentives,&vulnerabilities&and&constraints,!Fafo!paper!2008/26!(2008).!Available!at!http://www.fafo.no/pub/rapp/10070/10070.pdf!!


192!Haiti!Education!Cluster,!Education&cluster&information&bulletin:&24&September&2011!(September!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/news/Edu_Cluster_info_bulletin_23_sept_eng.pdf!

193!J.!Juste,!Haiti:&Digicel&CEO&wants&to&know&where&the&education&money,!Defend.ht!(6!January!2012).!Available!at!http://www.defend.ht/money/articles/business/2398`haiti`digicel`ceo`wants`to`know`whereìs`theèducation`money!

194!Defend.ht,!“National&fund&for&education&is&not&operational”&says&Haiti&Education&Minister,!Defend.ht!(26!November!2011).!Available!at!http://www.defend.ht/politics/articles/executive/2075`qnational`fund`forèducationìs`notòperationalq`says`haitièducation`minister!

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Conclusion.The!protection!of!Haiti’s!children!depends!on!the!development!of!sustainable!inter`sectoral!strategies!to!restore,!protect,!and!promote!children’s!rights.!Despite!impressive!progress!in!many!areas!following!the!January!2010!earthquake,!key!gaps!remain! in! the!comprehensive!protection!of!Haiti’s!children.!As!the!Government!and!international!responders!transition!to!medium`!and!long`term!rehabilitation!strategies,!maintaining!the!achievements!attained!thus!far! is! imperative!to!ensure!that!programs!and!policies!are!sustainable!and!that!the!best!interests!of!the!child!remain!the!cornerstone!of!evidence`based!decision`making.!! !

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1.&Introduction&

©!2012!FXB!Center!for!Health!and!Human!Rights! 1!

1.&Introduction&!The! Haitian! earthquake! of! January! 12,! 2010! struck! a! country! whose! history! has! been! marked! by!hardship.!The!displacement!of!the!native!Taino!population!by!Spanish!colonists!in!1492!was!followed!by!the! importation!of!African! slaves! to! support! sugar! cane!production!and,! in!1697,! transition! to! French!rule.195!In!1804,!the!first!successful!slave!rebellion!in!the!world!led!Haiti!to!became!the!first!independent!nation!in!Latin!America.!From!then!until!1986,!with!the!fall!of!the!hereditary!Duvalier!dictatorship,!Haiti!was!ruled!by!a!succession!of!repressive!regimes!and!dictators!who!preserved!power!at!the!expense!of!the!people.!The!new!Constitution!of!1987!laid!the!foundation!for!Haiti’s!present!political!system,!which!was!itself!characterized!by!violence!and!bloodshed!until!at!least!2004.196,197!!The!past!decade!has!dramatically!witnessed!Haiti’s!geographic!vulnerability!to!natural!disasters.!In!2004,!floods!in!Fonds`Verrettes!and!Mapou!followed!by!Tropical!Storm!Jeanne!left!more!than!5,000!dead!and!caused!US$250!million!of!damage.198!Four!years!later,!in!2008,!Haiti!was!buffeted!by!Tropical!Storm!Fay!and! Hurricanes! Gustav,! Hanna,! and! Ike! within! one!month,! leaving! 800! dead,! one!million! in! need! of!humanitarian! assistance,! and! damage! worth! 15%! of! Haiti’s! GDP.199! In! 2009,! the! United! Nations!Development!Programme!(UNDP)!ranked!Haiti!as!the!poorest!country!in!the!Western!Hemisphere.200!!The!earthquake!of!January!2010!was!the!largest!natural!disaster!in!Haiti’s!history,!both!in!terms!of!lives!lost!and!economic!cost.!Striking!25!km!west`south`west!of!Port`au`Prince!at!a!depth!of!roughly!13!km!below! the! surface,! the!7.0!Richter! scale!earthquake!shook! for!35! seconds.201!According! to! the!Haitian!government!in!March!2010,!over!220,000!people!lost!their! lives,!more!than!300,000!were!injured,!and!more! than!1.5!million!were!directly!affected.202!Some!sources!believe! the!number!of!deaths! to!be! far!higher,! with! up! to! 316,000! killed,! while! others! suggest! as! few! as! 100,000! casualties,203! though!most!sources! cite! the! official! Haitian! government! estimate! of! 220,000! deaths.! Physical! damage! alone! has!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!195!J.!Dayan,!“Haiti,!History,!and!the!Gods,”!in!G.!Prakash!(ed.),!After&Colonialism:&Imperial&Histories&and&Precolonial&

Displacements!(Princeton:!Princeton!University!Press,!2001).!196!ALNAP,!Haiti&earthquake&response:&Context&analysis!(July!2010).!Available!at!http://www.alnap.org/pool/files/haiti`context`analysis`final.pdf!

197!N.!Caistor,!Haiti’s&history&of&misery,!BBC!News!(13!January!2010).!Available!at!http://news.bbc.co.uk/2/hi/americas/8456728.stm!




201!U.S.!Geological!Survey,!Magnitude&7.0&–&Haiti&Region:&Details,!Earthquake!Hazards!Program!(2010).!Available!at!http://earthquake.usgs.gov/earthquakes/eqinthenews/2010/us2010rja6/#details!!


203!U.S.!Geological!Survey,!Magnitude&7.0&–&Haiti&Region:&Summary,!Earthquake!Hazards!Program!(2010).!Available!at!http://earthquake.usgs.gov/earthquakes/eqinthenews/2010/us2010rja6/#summary!!

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2! ©!2012!FXB!Center!for!Health!and!Human!Rights!

been!estimated!at!US$7.8!billion—more!than!Haiti’s!total!GDP!in!2009.!Six!months!after!the!earthquake,!moreover,! UNICEF! estimated! that! 1.6! million! people! were! still! living! in! more! than! 1,300! Internally!Displaced!Person!(IDP)!camps.204!By!the!end!of!September!2011,!more!than!one!and!a!half!years!later,!approximately!550,000!people!remained!in!approximately!800!IDP!camps.205!!As! noted! by! UNICEF,! the! 2010! Haitian! earthquake! was! a! children’s! disaster.206! Overlaid! on! a! bed! of!chronic!poverty!and! insecurity,! the!earthquake!created!new! risks! to! child!protection!and!exacerbated!pre`existing! vulnerabilities.! In! 2010,! Haiti’s! 4.25! million! children! accounted! for! 42.5%! of! the! total!population.207!1.5!million!children!are!reported!to!have!been!affected!by!the!earthquake,!while!800,000!were! believed! to! be! residing! in! IDP! camps! by! July! 2010.208! Furthermore,! 38%! of! registered! IDPs! by!December! 2010! were! children.209! Assuming! this! proportion! has! remained! constant,! approximately!209,000!children!would!be!expected!to!be!living!in!camps!in!September!2011.!!!Children! are! a! vulnerable! group! in! any! emergency,! as! their! means! of! survival! and! development! are!inextricably! mediated! by! other! actors,! be! they! the! family,! the! community,! or! the! state! as! a! whole.!UNICEF!states!that!“the!family!can!be!the!single!most!important!factor!in!determining!whether!or!not!a!child!is!protected.”210!As!a!result,!the!Sphere!Project!has!identified!the!family!as!“a!fundamental!unit!for!the! protection! of! persons,! and! as! a! prime,! motivating! factor! in! the! decision`making! of! the! affected!persons.”211! In! post`disaster! contexts,! such! as! Haiti,! the! protection! of! children! must! therefore! be!situated! in! a! broader! social! context,! encompassing! the!means! and! strategies! available! to! children! as!they!and!their!care`givers!seek!to!overcome!hardship!and!realize!their!rights.!!For!operational!purposes,!UNICEF!uses!the!term!child!protection!“to!refer!to!preventing!and!responding!to! violence,! exploitation! and! abuse! against! children—including! commercial! sexual! exploitation,!trafficking,! child! labor!and!harmful! traditional!practices,! such!as! female!genital!mutilation/cutting!and!child!marriage.”212! Also! targeted! for! child! protection! are! children! at! heightened! risk! of! these! abuses,!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!204!UNICEF,!Children&of&Haiti:&Milestones&and&looking&forward&at&six&months!(July!2010).!Available!at!http://www.unicef.org/emerg/files/UNICEF_Haiti_`_Six_Months_Report_Final.pdf!!

205!IOM,!Population&in&camps&housing&Haitians&left&homeless&by&the&2010&earthquake&drops&below&600,000,!International!Organization!for!Migration!(August!2011).!Available!at!http://www.iomhaiti.com/ft/page.php?id=53!!


207!World!Bank,!World&databank&education&statistics&(EdStats).!Available!at!http://data.worldbank.org/data`catalog/ed`stats!


209!IOM,!Registration,!International!Organization!for!Migration!(December!2010).!Available!at!http://www.iomhaiti.com/ft/pdf/Brochure.CCCM.Registration.Dec.10.pdf!!

210!UNICEF,!Child&protection:&A&handbook&for&parliamentarians,!Handbook!for!Parliamentarians!No.!7!(2004).!Available!at!http://www.unicef.org/publications/files/Guide_Enfants_OK.pdf!!

211!Sphere!Project,!Sphere&protection&section:&Draft!(June!23,!2011).!Available!at!http://www.crin.org/docs/FileManager/Sphere_Protection_Chapter_23Junedraft1.doc!!

212!UNICEF,!Child&protection&information&sheets!(May!2006).!Available!at!http://www.unicef.org/publications/files/Child_Protection_Information_Sheets.pdf!!

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1.&Introduction&


such!as!those!without!parental!care,!in!armed!conflict,!and!those!in!conflict!with!the!law.213!While!useful!for! operational! purposes,! this! “categorization”!of! child! protection! conflates! characteristics! of! risk! and!need,! and! the! assessment! of! need! itself.! In! order! to! assess! child! protection! holistically! in! the!Haitian!context,!a!broader!definition!is!required!that!encompasses!a!wider!range!of!child!protection!risk!factors,!as! well! as! the! outcomes! and! the! dynamic! processes! that! connect! them.! The! Inter`Agency! Standing!Committee—the! principal! international! mechanism! for! the! coordination! of! humanitarian! assistance!between!non`governmental!organizations!and!the!United!Nations—proposed!the!following!definition!of!protection!under!their!1999!framework!for!the!protection!of!internally!displaced!persons:!!

The!concept!of!protection!encompasses!all!activities!aimed!at!obtaining!full!respect!for!the!rights!of!the!individual!in!accordance!with!the!letter!and!the!spirit!of!the!relevant!bodies!(human!rights,!humanitarian!law,!and!refugee!law).214!

!When! applied! to! children,! this! definition! recognizes! that! child! protection! requires! a! multi`tiered!framework,!whereby!the!child’s!experience!is!not!assessed!in!isolation,!but!rather!in!the!context!of!what!is!available!and!can!be!provided!by!the!family,!the!community,!and!the!state!as!a!whole.!Additionally,!it!affirms!the!notion!that!human!security!is!not!merely!the!absence!of!violence,!exploitation!or!abuse,!but!an! enabling! and! fostering! environment! that! expands! the! opportunities! available! to! the! child.215!Facilitating! a! broader! analysis! of! risk! factors,! systems,! and! outcomes,! this! approach! requires! a!more!comprehensive!assessment!of!children’s!lived!experience!in!realizing!their!rights.!!This! report! analyzes! child! protection! risk! factors! and! outcomes! in! Haiti! before! and! after! the! January!2010!earthquake,!highlighting!ways!in!which!children’s!vulnerabilities!and!resilience!are!affected!by!and!translated! into! the! realization! or! violation! of! their! rights.! To! help! guide! and! identify! areas! for! future!research,! the! report!also!highlights! current!gaps! in! the!knowledge!of! child!protection! risk! factors!and!outcomes.! Striving! to! provide! a! holistic! assessment! of! child! protection! in! Haiti,! it! aims! to! empower!policymakers!and!programmers!to!build!a!better!Haiti!for!its!children.!

!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!213!UNICEF,!Child&protection&information&sheets!(May!2006).!Available!at!http://www.unicef.org/publications/files/Child_Protection_Information_Sheets.pdf!!

214!ICRC,!Report&of&the&third&workshop&on&protection&for&human&rights&and&humanitarian&organizations:&Doing&

something&about&it&and&doing&it&well,!18`20!January!1999!(January!2000).!215!Sphere!Project,!Humanitarian&charter&and&minimum&standards&in&humanitarian&response!(2011).!Available!at!http://www.sphereproject.org/!!

!


2.&Methodological&note&!This!Report!directly!examines!the!protection!risk!factors!and!outcomes!experienced!by!children!in!Haiti!before!and!after!the!January!12,!2010!earthquake,!in!addition!to!other!risk!factors!and!outcomes!that,!while! not! directly! associated! with! children,! influence! their! lives.! The! Report! also! aims! to! assess! the!currently! available! body! of! knowledge! of! child! protection! in! Haiti,! and! highlight! areas! where! this!knowledge!should!be!expanded,!deepened,!or!re`oriented.!In!most!cases,!existing!data!are!outdated!in!light! of! the! 2010! earthquake.! The! absence! of! a! large`scale,! nationally! representative! survey! covering!many!of! the! topics! addressed! in! this!Report!necessitates! a!new!comprehensive! assessment,! updating!estimates!of!phenomena!of!interest,!and!facilitating!correlation!analysis.!This!Report!fulfills!the!first!step!of!this!endeavor!by!examining!what!is!known!about!Haitian!children’s!lived!experiences!today,!analyzing!key!aspects!of!the!situation!in!the!recent!past,!and!identifying!areas!that!demand!further!inquiry.!!This!Report!draws!information!from!a!wide!range!of!sources,!including!international!organizations!such!as! the! United! Nations! (UN)! and! its! agencies,! the! International!Monetary! Fund! (IMF),! and! the!World!Bank,! as! well! as! the! offices! of! the! Haitian! government! and! other! states,! the! academic! and! research!community,!and!the!plethora!of!relief!and!development!organizations!operating!within!Haiti!both!before!and!since!the!earthquake.!A!primary! literature!catchment!was!conducted! in!July!and!August!2010!and!then! supplemented! by! further! catchments! in! January! 2011,! June`September! 2011,! and! ongoing!research.! Information! from! international! organizations! was! primarily! collected! through! the! Haiti!oneResponse!website,!manual!and!key`word!searches!on!relevant!organizations’!websites,!and!general!searches! using! Google.! Sources! produced! by! the! Haitian! government! were! obtained! through! online!searches,! the! Haiti! oneResponse! website,! and! hard! copy! collection! by! FXB! Center! team!members! in!Haiti.! Information!collected!from!other!country!governments!was!collected!through! internet!searches.!Academic! sources! were! collected! through! searches! on! Google! and! Google! Scholar,! the! Harvard!University! Hollis! library! catalogue,! PubMed,! the! Harvard! humanitarian! and! human! rights! community,!and!the!Haiti!oneResponse!website.!Information!from!international!relief!and!disaster!organizations!was!sourced! online! through! general! web! searches! using! Google! and! targeted! key`word! and! manual!searching!on!the!websites!of! large!relief!and!development!organizations!registered!with!the!UN!Office!for! the!Coordination!of!Humanitarian!Affairs! (UN!OCHA)! in!Haiti.! In!addition,!“snowball”! research!was!conducted!using!the!reference!lists!of!seminal!and!authoritative!documents.!!For!the!purposes!of!this!Report,!“children”!are!defined!according!to!Article!1!of!the!Convention!on!the!Rights!of!the!Child!as!the!population!that!has!not!yet!reached!their!18th!birthday,!i.e.,!individuals!aged!0!to!17.216!Adolescents!are!defined!according!to!UNICEF!standards!as!individuals!aged!10!to!19.!Similarly,!youth!are!defined!as!those!age!15!to!24.!In!many!cases!throughout!the!Report,!other!age!categories!are!used,!such!as!“children!who!are!under!5!years!of!age,”!or!those!who!are!“school`aged.”!These!cases!are!accordingly!highlighted!in!the!text.!In!some!instances,!lack!of!international!consensus!on!the!definitions!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!216!Convention!on!the!Rights!of!the!Child,!G.!A.!Res.!44/25!(1989).!Available!at!http://www2.ohchr.org/english/law/crc.htm!!

2.&Methodological&note&


of!“child,”!“adolescent,”!and!“youth”!lead!to!a!lack!of!comparability!among!sources.!In!such!cases,!the!definitional!discrepancy!is!either!highlighted,!or!another!authoritative!source!is!used!when!available.!!Unless!otherwise!noted,!figures!presented!in!this!Report!appear!in!their!original!form.!!Finally,! the! Report! assesses! the! levels! and! trends! of! pertinent! risk! factors! and! outcomes,! and! is!organized! into! a! series! of! sections! each! containing!multiple! topics.! Each! topic! first! examines! Haitian!children’s! experiences! before! the! earthquake! and! highlights! knowledge! gaps! before! discussing! the!impact!of!the!earthquake!on!children!regarding!that!area!of!interest.! In!general,!each!topic!progresses!from!general!to!specific,!discussing!broad!themes!before!going!into!further!detailed!and!focused!inquiry.!Associations! are! drawn! between! topics,! and! cross`references! direct! the! reader! to! other! relevant!information!contained!within!the!Report.!!

!


3.&Demography&!Since! the! end! of! the! Duvalier! regime! in! 1986,! Haiti’s! population! has! undergone! significant!transformation! in! terms!of! size,! composition,! distribution,! and! rate!of! growth.! The!paucity! of! reliable!historical!data!makes!it!difficult!to!reconcile!estimates!of!Haiti’s!total!population,!which!differ!by!source.!According!to!the!World!Bank,!Haiti’s!total!population!increased!from!approximately!5.7!million!in!1980!to!around!10!million!in!2010!(Figure!1),217!exhibiting!an!average!(crude)!growth!rate!of!2.5%!per!annum.!However,!over!this!same!period,!significant!out`migration!has!tempered!the!domestic!impact!of!Haiti’s!high!prevailing!Total!Fertility!Rate!(TFR),!defined!as!the!number!of!births!the!average!woman!is!likely!to!have! over! the! course! of! her! reproductive! years,! assuming! that! she! is! subject! to! current! age`specific!fertility! rates.! Out`migration! has,! therefore,! simultaneously! provided! the! country! with! significant!opportunities! for! remittance! flows! from!migrants’! destination! countries! and! reduced! the! burden! on!strained!domestic!services.!!Figure.1:.Total.Haiti.domestic.population,.1980T2010.

!Data!source:!World!Bank,!World&development&indicator&database.!Available!at!http://databank.worldbank.org/ddp/home.do?Step=12&id=4&CNO=2!

!!The!population!has!grown!differentially!across!Haiti’s!ten!administrative!Departments.!A!2008!review!by!Dorte!Verner!highlights!the!diversity!of!experiences!between!regions!in!2003,!when!Haiti!had!only!nine!Departments!(Figure!2).!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!217!World!Bank,!World&development&indicator&database.!Available!at!http://databank.worldbank.org/ddp/home.do?Step=12&id=4&CNO=2!

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3.&Demography&


Figure.2:.Population,.household.size.and.gender.ratio,.by.Department,.2003.

!Source:!IHSI!(2003),!in!D.!Verner,!Making&poor&Haitians&count:&Poverty&in&rural&and&urban&Haiti&based&on&the&first&

household&survey&for&Haiti,!World!Bank!Sustainable!Development!Division!(March!2008).!Available!at!http://go.worldbank.org/AE6TJ7EPY0!!

!!In! Verner’s! analysis,! population! growth! included! births,! deaths,! and! domestic! and! international!migration.!While!the!impact!of!urbanization!and!migration!will!be!discussed!in!greater!detail!later!in!this!Report,!it!is!worth!noting!here!that!during!the!period!of!1982`2003,!Ouest!Department,!which!includes!the! capital! Port`au`Prince,! demonstrated! both! the! largest! total! population! and! greatest! population!growth.! The! lowest! population! growth! in! this! period! was! in! Grande’Anse! and! Sud`Est! Departments,!which!are!primarily!agricultural!regions.!!Figure.3:.Annual.domestic.population.growth.rate,.1980T2010.


!


!!Since!the!early!1980s,!Haiti!overall!has!experienced!a!declining!annual!population!growth!rate!(Figure!3).!In!2010,!the!World!Bank!estimated!Haiti’s!annual!population!growth!rate!to!be!1.3%!per!annum.218!The!2010! Human! Development! Report! projects! Haiti’s! annual! population! growth! rate! to! remain! low,!averaging!1.5%!per!annum!for!the!2010!–!2015!period.219!This!declining!growth!rate!is!the!result!of!three!factors:! a! reduction! in! fertility! (see! Section! 3C.& Fertility,! below),! limited! changes! in! age`specific! life!expectancies! (see! Section! 3E.& Mortality,! below),! and! continued! out`migration.! However,! despite! a!reduction!in!the!rate!of!population!growth,!Haiti!continues!to!experience!increasing!population!pressure!on!its!natural!resources,!services,!and!institutions.!Haiti!is!the!second!most!densely!populated!country!in!the!Americas,!with!an!average!of!306!people!per!square!kilometer!in!2006.220!!Figure.4:.Population.under.age.18,.1990T2010.

!Data!source:!World!Bank,!World&databank&education&statistics&(EdStats).!Available!at!http://data.worldbank.org/data`catalog/ed`stats!

!!


219!UNDP,!Human&development&report&2010:&The&real&wealth&of&nations:&Pathways&to&human&development!(New!York:!Palgrave!Macmillan,!2010).!Available!at!http://hdr.undp.org/en/reports/!!


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3.&Demography&


Figure.5:.Proportion.of.total.Haitian.population.under.age.18,.1990T2010.

!Data!source:!World!Bank,!World&databank&education&statistics&(EdStats).!Available!at!http://data.worldbank.org/data`catalog/ed`stats!

!!Over!the!period!of!1990`2010,!the!number!of!children!in!Haiti!increased!by!approximately!21.6%!(Figure!4),!from!roughly!3.5!million!in!1990!to!4.25!million!in!2010.221!However,!the!share!of!the!total!population!comprised!of!children!fell!by!6.54%!between!1990!and!2010.!In!1990,!children!accounted!for!49%!of!the!total!Haitian!population,!while! in!2010,! they!accounted! for!42.5%.222!Between!1994`95!and!2000,! the!median! age! of! the! population! increased! from! 18.5! to! 18.9! years.223! The! World! Bank! attributes! the!decline! in!the!share!of!the!population!under!age!18!to!“the!twin!effects!of!urbanization!(fertility!rates!were!lower!in!urban!areas!than!in!the!countryside)!and!gradually!declining!fertility!rates!overall!(partly!as!a!result!of!increased!educational!attainment).”224,225!!A!World!Vision!rapid!assessment!of!60!camps!and!communities!in!the!Port`au`Prince!metropolitan!area!and!the!organization’s!operational!areas!in!La!Gonâve,!Plateau!Central,!and!Nord!and!Sud!Departments!in! February!2010! found!average!household! age! composition! to!be! comparable! to! the!pre`earthquake!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!221!World!Bank,!World&databank&education&statistics&(EdStats).!Available!at!http://data.worldbank.org/data`catalog/ed`stats!


223!D.!Verner,!Making&poor&Haitians&count:&Poverty&in&rural&and&urban&Haiti&based&on&the&first&household&survey&for&

Haiti,!World!Bank!Sustainable!Development!Division!(March!2008).!Available!at!http://go.worldbank.org/AE6TJ7EPY0!!




!


situation! (Figure!6).226!Though! the!survey!was!not! random!and!had!a! limited!sample!size,! the! findings!suggest!that!earthquake!mortality!did!not!disproportionately!affect!any!specific!age!group,!and!that!pre`earthquake!household!age!composition!ratios!remain!valid.!!Figure.6:.Age.composition.of.surveyed.households.(hh),.February.2010.

!Source:!World!Vision,!Rapid&assessment&report:&Haiti&earthquake&response!(March!2010).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/Full_Report_583.pdf!!

!!The! changing! age! composition! of! Haiti’s! population! can! be! seen! in! its! population! pyramid,! which!graphically!displays!the!proportion!of!the!population!in!each!five`year!age!group!(Figure!7!and!Figure!8).!In!2000,!Haiti’s!population!pyramid!conformed!to!the!typical!shape!of!a!developing!country,!where!the!share!of!the!population!in!each!ascending!age!group!is!smaller!than!that!of!the!preceding!age!group.!In!2010,!however,!the!population!pyramid!shows!that!the!proportion!of!Haiti’s!population! in!the!0`4!age!group!was! smaller! than! that! in! the! 5`9! age! group.! If! sustained,! this! effect! is! called! the! demographic!transition.!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!226!World!Vision,!Rapid&assessment&report:&Haiti&earthquake&response!(March!2010).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/Full_Report_583.pdf!!

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3.&Demography&


Figure.7:.Haiti.population.pyramid,.2000.

!Data!source:!U.S.!Census!Bureau,!International&data&base:&Haiti&demographic&indicators.!Available!at!http://www.census.gov/population/international/data/idb/informationGateway.php!

!!

Figure.8:.Haiti.population.pyramid,.2010.

!Data!source:!U.S.!Census!Bureau,!International&data&base:&Haiti&demographic&indicators.!Available!at!http://www.census.gov/population/international/data/idb/informationGateway.php!

!


!!While! Haiti’s! population! is! still! growing,! the! proportion! of! its! population! in! the! youngest! age! groups!(ages! 0`19)! is! falling,! due! to! lower! fertility! rates! among! women! in! their! reproductive! years,! ceteris&paribus.! As! noted! previously,! the! proportion! of! the! population! under! age! 18! has! fallen! since! 1993,!reflecting!the!relative!stability!of!age`specific!life!expectancies!and!decreases!in!fertility!over!that!period.!!The!population!proportions!illustrated!in!Figure!8!for!age!groups!0`4,!5`9,!10`14,!and!15`19!also!indicate!a!“youth!bulge”!moving!through!Haiti’s!population!structure.!Youth!bulges!present!both!challenges!and!opportunities.! These! opportunities,! collectively! referred! to! as! the! “demographic! window! of!opportunity,”!derive!from!the!potential!of!a!low!“dependency!ratio”!to!stimulate!economic!growth!and!development,!leading!to!a!“demographic!dividend.”227!The!dependency!ratio!is!the!ratio!of!the!segment!of!the!population!in!the!working!age!range!(15`64)!to!the!combined!population!segment!younger!than!age!15!and!aged!65!and!over.!As!such,!the!dependency!ratio!can!be!conceived!of!as!the!average!number!of!dependents!for!each!person!in!the!working`age!population.!Lower!dependency!ratios!are,!therefore,!preferable! to! large! dependency! ratios,! as! each! person! of! working! age! is! responsible! for! fewer!dependents,! thereby!enjoying!a!higher! share!of!his!or!her! total! earnings.!Bloom,!Canning,! and!Sevilla!propose!that!the!movement!of!a!youth!bulge!through!the!population!structure!was!one!of!the!primary!reasons!that!many!East!Asian!economies!were!able!to!elicit!impressive!economic!growth!over!the!past!20! years.228! As! the! youth! bulge! moves! up! into! the! older! age! groups,! a! greater! proportion! of! the!population!will!be!in!the!working`age!segment!of!the!population.! If!gainful!employment! is!available!to!the!population,!the!movement!of!this!group!through!the!working!ages!will!fuel!economic!growth,!as!the!lower!dependency!ratio!will!allow!them!to!save!and/or!invest!more!of!their!earnings.!!!While!the!observed!youth!bulge!provides!Haiti!with!many!opportunities,!lack!of!options!for!children!and!young! people! expose!many! concomitant! challenges.! As!will! be! discussed! in! Chapters! 8! and! 9! of! this!Report,!children! in!Haiti!do!not!enjoy!the!human!capital!and!positive!employment!options!required!to!capitalize!on! the!demographic!window!of!opportunity.!Education!quality! is!poor,!depriving!children!of!the!knowledge!and!skills!necessary!to!realize!potential!gains!of!the!demographic!transition.!A!shortage!of! employment! and! sustainable! livelihood! opportunities! thus! stymie! chances! for! rapid! growth.! The!potential! effects!of! the!youth!bulge! therefore! stand! in! stark! contrast! to!each!other.! If!Haiti! is! able! to!rebuild! from! the! January! 2010! earthquake! in! a! manner! that! promotes! the! holistic! protection! and!development!of! its!children,!promoting!a!safe!and!enabling!environment!for!their!physical!and!mental!development!while!bolstering!the!availability!of!gainful!employment!opportunities,!the!youth!bulge!may!be! an! engine! for! growth! and! poverty! reduction.! If,! on! the! other! hand,! children! are! not! protected,!necessary! investments! in! human! security! and! development! are! not!made,! children! are! not! equipped!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!227!D.!E.!Bloom,!D.!Canning,!and!J.!Sevilla,!The&demographic&dividend:&A&new&perspective&on&the&economic&

consequences&of&population&change,!RAND!population!matters!monograph!No.!MR`1274!(2003).!Available!at!http://www.rand.org/pubs/monograph_reports/2007/MR1274.pdf!

228!D.!E.!Bloom,!D.!Canning,!and!J.!Sevilla,!The&demographic&dividend:&A&new&perspective&on&the&economic&


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3.&Demography&


with!the!skills!and!capacities!necessary!to!prosper!through!their!working!years,!and!Haiti!continues!on!its!preèarthquake!trajectory,!the!youth!bulge!will!result!in!higher!unemployment!and!the!consolidation!and! deepening! of! poverty,! increasing! the! attractiveness! of! maladaptive! survival! strategies! and!undermining! social!welfare.! Investing! in! child!protection! is,! therefore,! of! critical! importance! to!Haiti’s!future.!!!

A.&Urbanization&!Haiti’s!population!has!continued!to!urbanize!over!the!past!30!years!(Figure!9).!Between!1980!and!2010,!the!proportion!of!the!population!living!in!urban!areas!grew!from!20.5%!to!49.6%—!an!increase!of!142%,!or!a!simple!average!urbanization!rate!of!4.7%!per!annum.229,230!In!the!period!of!1986!to!2006,!the!Portàu`Prince!metropolitan!area!received!an!average!of!75,000!internal!migrants!per!annum,!in!addition!to!its! natural! annual! growth! rate! of! 40,000! people,! together! accounting! for! growth! in! the!metropolitan!area!of!115,000!people!per!year.231!Between!1982!and!2003,!every!Department! in!Haiti! registered!an!increase! in! urban! population! share! (Figure! 10),232!while! the! proportion! of! the! total! urban! population!residing! in! the!capital! fell! from!60.09%! in!1980! to!55.56%! in!2009.!By! July!2010,! six!months!after! the!earthquake,! the! World! Bank! estimated! that! this! proportion! had! fallen! further,! to! 43.24%,! due! to!earthquake`related!migration! out! of! the! capital.233! It! is! unclear! whether! this! reduced! proportion! has!remained!constant,!or!whether!the!proportion!of!the!total!urban!population!living!in!Portàu`Prince!has!returned!to!preèarthquake!levels.!!


230!Population!Reference!Bureau,!PRB&datafinder:&Haiti.!Available!at!http://www.prb.org/datafinder.aspx!231!World!Bank,!Social&resilience&and&state&fragility&in&Haiti:&A&country&social&analysis,!Caribbean!Country!Management!Unit,!Report!no.!36069`HT!(April!2006).!Available!at!http://siteresources.worldbank.org/SOCIALANALYSIS/1104894`1115795935771/20938696/Haiti_CSA.pdf!!




!


Figure.9:.Percentage.of.population.living.in.urban.and.rural.areas,.1980T2010.


!!Figure.10:.Percentage.of.Haiti's.population.in.urban.areas:.National.and.by.Department,.1982.&.2003.

!Source:!D.!Verner,!Making&poor&Haitians&count:&Poverty&in&rural&and&urban&Haiti&based&on&the&first&household&survey&

for&Haiti,!World!Bank!Sustainable!Development!Division!(March!2008).!Available!at!http://go.worldbank.org/AE6TJ7EPY0!!

!!Both! the!absolute!number!and!percentage!of! the!urban!population! living! in! slums! increased!between!1990!and!2001,!from!1.7!million!(84.9%!of!total!urban!population)!in!1990,!to!2.6!million!(85.7%!of!urban!population)!in!2001.!However,!both!the!absolute!number!and!percentage!living!in!slums!in!urban!areas!then!decreased!between!2001!and!2005,!to!2.3!million!(70.1%!of!urban!population).234!Therefore,!while!the! absolute! number! of! people! living! in! slums! in! urban! areas! increased! by! approximately! 590,000!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!234!DevInfo,!MDG&database&2010:&Haiti.!Available!at!http://www.devinfo.info/mdginfo2010/!

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3.&Demography&


between!1990!and!2005,!the!proportion!of!urban!residents!living!in!slums!decreased!by!17.4%!from!the!1990!level—an!absolute!reduction!in!the!proportion!of!the!urban!population!living!in!slums!of!14.8%.!!There! is!a!higher!proportion!of! female! than!male!adolescents! living! in!urban!areas.! In!2006,!40.3%!of!girls!aged!10`14!and!47.2%!aged!15`19!lived!in!urban!areas,!compared!to!32.0%!of!boys!aged!10`14!and!39.4%!aged!15`19.235!As!such,!girls!aged!10`14!were!25.9%!more!likely!to!reside!in!urban!areas!than!boys!of! the!same!age,!while!girls!aged!15`19!were!19.8%!more! likely! to! live! in!urban!areas! than!their!male!counterparts.! This! lack! of! parity! is! attributed! to! discrepancies! in! the! types! of! labor! sought! by! each!gender;!women!generally!migrate!to!urban!areas!in!search!of!employment!in!export!processing!zones!or!as! domestic! servants,! while! men’s! traditionally! agricultural! work! profile! has! led! them! to! seek! more!opportunities!in!rural!areas.236!For!this!reason,!it!is!believed!that!twice!as!many!women!as!men!migrate!from!rural!to!urban!areas.237!!!

B.&Vital&registration&!Vital!registration!is!the!official!government!recording!of!major!life!events!of!its!population,!such!as!births!and! deaths.238! As! noted! by! UNICEF,! birth! registration! “is! fundamental! to! the! realization! of! children’s!rights!and!practical!needs,”!contributing!to!their!right!to!an!identity!and!opening!the!way!for!civic!and!economic!engagement.239!Birth!registration!may!assist!individuals!to!obtain!credit,!apply!for!a!passport,!vote,! and! entitle! them! to! immunizations! and! school! access.! It! is! also! critical! for! child! protection,! as!registered! children! are! better! able! to! access! legal! protections,! are! more! visible! in! child! trafficking!investigations! and! anti`child! marriage! policies,! and! are! more! easily! reunited! with! family! members!following!domestic!or! international! repatriation.!Finally,!birth!registration!allows! for!more!appropriate!budgetary!procedures!as!population!estimates!are!more!reliable.! It!therefore!has!two!major!purposes:!legal!and!statistical.240!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!235!Population!Council/UNFPA,!The&adolescent&experience&in5depth:&Using&data&to&identify&and&reach&the&most&


236!World!Bank,!A&review&of&gender&issues&in&the&Dominican&Republic,&Haiti&and&Jamaica,!Report!No.!21866`LAC!(2002).!Available!at!http://www`wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2003/03/22/000094946_03030704005682/Rendered/PDF/multi0page.pdf!!




240!UNICEF,!The&‘rights’&start&to&life:&A&statistical&analysis&of&birth&registration!(February!2005).!Available!at!http://www.unicef.org/publications/index_25248.html!!

!


Prior! to!the!2010!earthquake,!Haiti!had!made!progress! towards!universal!birth!registration,! increasing!prevalence! from! 70%! at! the! turn! of! the! century! to! 81%! by! 2006.241! While! negligible! gender! bias! is!observed!in!registration!rates,!differences!are!observable!between!urban!(87%)!and!rural!(78%)!areas,242!mother’s! education! (64.4%! for! those! with! no! education! versus! 96.7%! for! those! with! a! tertiary!education),!and!socio`economic! status! (60.2%! for! lowest!quintile!versus!83.6%! for!highest!quintile).243!UNICEF! noted! with! interest! that! in! 2000,! Haitian! children! who! attended! early! childhood! education!programs!were!less!likely!(76%)!to!be!registered!than!those!who!did!not!(84%);!in!other!contexts,!birth!registration!is!usually!positively&associated!with!early!childhood!education!attendance.244!!Several! barriers! to! birth! registration! exist! in! Haiti.! First,! the! distribution! of! civil! registry! offices!disenfranchises!rural!children,!as!there!are!few!offices!outside!of!the!capital!and!none!in!rural!areas.245!UNICEF!has!also!noted!that!the!costs!of!registering!a!child,!both!financially!in!terms!of!official!costs!and!informally!in!terms!of!lost!time,!may!not!be!deemed!worthwhile.!Lack!of!knowledge!of!where!to!register!a!birth!may!be!another!barrier,!along!with!a!lack!of!understanding!of!the!importance!of!the!registration!process.246! Conflict! situations,! such! as! periods! of! civic! unrest,! have! also! been! found! to! lower! the!likelihood!of!birth!registration.247!!The!Haitian!government!has!attempted!to!address!sub`optimal!birth!registration.!In!1995,!a!Presidential!Decree! created! an! opportunity! for! those! whose! birth! had! not! been! registered! to! bypass! the! late!registration! process.! Additionally,! the! country! instituted! a! new! process! in! which! a! child! may! be!registered! by! parish! administrative! services! at! a! child’s! baptism—a! rite! of! passage! highly! regarded! in!Haitian! culture.248! It! is! unclear! whether! the! rise! in! birth! registration! between! 2000! and! 2008! can! be!attributed! to! this! collaboration! between! church! and! state,! or! whether! increasing! levels! of! female!education!are!a!more!important!factor.!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!241!UNICEF,!State&of&the&world’s&children&200452009!(Oxford:!Oxford!University!Press,!2004`2009).!Available!at!http://www.unicef.org/sowc/!!




245!UN!Committee!on!the!Rights!of!the!Child,!Consideration!of!reports!submitted!by!state!parties!under!article!44!of!the!Convention:!Haiti,!UN!Doc.!CRC/C/51/Add.7!(2002).!Available!at!http://www.unhcr.org/refworld/docid/3df59ad34.html!!


247!UN!ESC,!Situation!of!human!rights!in!Haiti,!UN!Doc.!E/CN.4/2006/115!(2006).!Available!at!http://ap.ohchr.org/documents/dpage_e.aspx?m=47!!


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3.&Demography&


Haiti!maintains!a!critically!low!rate!of!death!certification.!In!1997,!death!certificates!were!completed!for!only!6.3%!of!deaths,! and! coverage!had! increased! to!only!10%!by!2003.! Subsequently,! a! large!drop! in!coverage!occurred!in!2004!and!2005!at!roughly!the!same!time!as!civil!unrest!spread!nationwide.!Despite!lower! coverage,! the! quality! of! the! certification! process! improved,! with! the! proportion! of! ill`defined!causes!falling!from!48%!in!1999!to!26%!in!2002.249!!!

C.&Fertility&!Haiti!displays!a!young!age!of!sexual!debut,!though!prevalence!varies!by!data!source.!According!to!the!!2009! Children! and! AIDS! report,! 42%! of! men! and! 15%! of! women! had! sex! before! age! 15! in! 2008,250!compared!to!worldwide!rates!of!20%!of!men!and!8%!of!women!in!1994!as!cited!in!the!2007!World!Youth!Report.251! Following! a! nationwide! survey! in! 2005`06,! the! Institut! Haitien! de! l’Enfance! found! that! the!percentage!of!young!people!of!both!genders!having!sex!before!age!15!was!increasing!over!time!(Figure!11),!as!was!the!proportion!having!sex!before!age!18.252!!Figure.11:.Percentage.of.young.Haitians.who.had.first.intercourse.before.15.or.before.18,.2006.

!Source:!Institut!Haitien!de!l’Enfance,!HIV/AIDS&in&Haiti:&Key&findings&of&the&mortality,&morbidity,&and&utilization&of&

services&survey!(2006).!Available!at!http://www.measuredhs.com/pubs/pub_details.cfm?id=767&srchTp=home!!!


250!UNAIDS,!Children&and&AIDS:&Fourth&stocktaking&report,&2009!(December!2009).!Available!at!http://www.unicef.org/publications/index_51902.html!!




!


Among!those!aged!15`19!who!had!ever!had!sex,!the!majority,!both!male!and!female,!had!sex!in!the!12!months!preceding!the!survey.253!As!Figure!12!illustrates,!males!in!all!age!categories!were!more!likely!to!report!having!had!sex!than!were!females!in!the!same!category.!!Figure.12:.Sexual.activity.among.Haitian.young.people,.2006.


services&survey!(2006).!Available!at!http://www.measuredhs.com/pubs/pub_details.cfm?id=767&srchTp=home!!!Prevalence!of! sexual!activity!among!young!people! is!not!uniform!across!Haiti,! varying!by! location!and!marital!status!(Figure!13).!Young!women!aged!15`19!in!the!Portàu`Prince!metropolitan!area!were!most!likely! to!be!sexually!active! (21.6%)!and!to!report!having!ever!had!sex! (47.2%),!while!those! in!NordÈst!(10.0%)!and!Sud!Departments!(10.1%)!were! least! likely!to!be!sexually!active.!Child!marriage!was!a!key!determinant! of! young! people’s! sexual! activity,! with! those! who! were! married! displaying! significantly!higher!rates!of!sexual!activity.!!!The!highest!rates!of!sexual!activity!among!females!aged!15`19!who!had!never!been!married!were!in!SudÈst! Department! and! the! Portàu`Prince! metropolitan! area! (10.6%! and! 10.1%,! respectively).! Ouest!Department! had! the! highest! prevalence! of! females! aged! 15`19! who! reported! ever! having! had! sex!(32.5%)! among! those!who!had!never!been!married.!Across! all!marital! categories,! females! aged!15`19!living! in! urban! areas! reported! higher! rates! of! sexual! activity! and! ever! having! sex! than! their! rural!counterparts.254!Education!also!plays!a!vital!role:!according!to!the!Population!Council!and!UNFPA,!“girls!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!253!Institut!Haitien!de!l’Enfance,!HIV/AIDS&in&Haiti:&Key&findings&of&the&mortality,&morbidity,&and&utilization&of&

services&survey!(2006).!Available!at!http://www.measuredhs.com/pubs/pub_details.cfm?id=767&srchTp=home!254!Population!Council/UNFPA,!The&adolescent&experience&in5depth:&Using&data&to&identify&and&reach&the&most&


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who!are! in! school!during!adolescence! (even! if! they!are!not! in! the!expected!grade! for! their! age)!have!lower!rates!of!reported!sexual!activity!than!their!out`of`school!peers.”255!!Figure.13:.Sexual.activity.among.15T19.year.old.females.(percent),.2006.

!Source:!Population!Council/UNFPA,!The&adolescent&experience&in5depth:&Using&data&to&identify&and&reach&the&most&


!!Since!1980,!Haiti!has!witnessed!a!marked!reduction!in!the!Total!Fertility!Rate!(TFR)!(Figure!14).!Over!this!time!period,!Haiti’s!TFR!peaked!in!1982,!with!an!average!of!6.15!births!per!woman.!Since!1982,!the!TFR!has!consistently! fallen,! resulting! in!a!TFR!of!3.4! in!2009.256!Accordingly,!Haiti’s! crude!birth! rate! fell!on!average!during!this!period,!from!41.9!births!per!1,000!total!population!in!1980,!to!27.0!births!per!1,000!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!255!Population!Council/UNFPA,!The&adolescent&experience&in5depth:&Using&data&to&identify&and&reach&the&most&



!


total!population!in!2009.257!However,!28.9%!of!currently!married!women!are!still!expected!to!have!five!or!more!children!over!the!course!of!their!reproductive!years.258!!Figure.14:.Total.Fertility.Rate.(TFR),.1980.T.2009.


!!Significant! fertility!differentials!exist!based!on!area!of! residence,!education,!and!economic! status.!The!1995!EMMUS! II! survey! found! that! “women! in! rural!areas! (5.9! children)…!give!birth! to!nearly! twice!as!many! children! (as)! in! the!Metropolitan! Area! (3.0! children).”259! The! same! study! revealed! that!women!with! no! education! gave! birth! to! more! than! twice! as! many! children! (6.1! children)! as! those! with! a!secondary!education!(2.5!children),260!supporting!the!World!Bank’s!assertion!that!women’s!fertility!falls!as!educational!attainment!increases.261!Similarly,!economic!status!greatly!affects!women’s!fertility.!The!


258!Population!Reference!Bureau,!PRB&datafinder:&Haiti.!Available!at!http://www.prb.org/datafinder.aspx!259!M.!Cayemittes,!A.!Rival,!G.!Lerebours,!and!B.!Barrere,!Survey&on&mortality,&morbidity&and&utilization&of&services&

(EMMUS5II)&1994/95:&Summary&report,!Demographic!and!Health!Surveys!(November!1995).!Available!at!http://www.measuredhs.com/pubs/pdf/SR49/SR49.pdf!!

260!M.!Cayemittes,!A.!Rival,!G.!Lerebours,!and!B.!Barrere,!Survey&on&mortality,&morbidity&and&utilization&of&services&



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TFR! of! women! in! the! poorest! income! quintile! is! 2.5! times! that! of! women! in! the! richest! income!quintile.262!!Little!data!exist!on!adolescent!fertility!before!1992,!and!different!sources!provide!varying!estimates.!In!1992,!the!UN!Statistics!Division!estimated!that!there!were!79!births!per!1,000!women!aged!15`19.!This!rate! increased! slightly! to! 80! births! per! 1,000! women! aged! 15`19! in! 1998,! before! falling! to! 68.6! in!2003.263!The!Pan`American!Health!Organization!has!estimated!that!the!15`19!year`old!fertility!rate!was!80! per! 1,000! girls! in! 2000264! and! 69! per! 1,000! girls! in! 2005/2006.265! These! estimates! are! higher! than!those!of!the!World!Bank,!which!estimated!fertility!among!Haitian!women!aged!15`19!to!be!61.8!births!per!1,000!women! in!1997,!51.3!births!per!1,000!women! in!2003,!and!44.3!births!per!1,000!women! in!2009! (Figure!15).266! In!2006,!14.6%!of!women!aged!15`19!had!either! given!birth!or!were!pregnant,267!indicating! a! negligible! reduction! since! 1995! (Figure! 16).268! In! 2002,! it! was! estimated! that! fertility!between! ages! 15`19! accounted! for! 8%! of! all! births! in! Haiti.269! The! significant! risks! associated! with!adolescent!childbirth!will!be!reviewed!in!Section!7C.&Sexual&and&reproductive&health.!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!262!D.!Verner,!Making&poor&Haitians&count:&Poverty&in&rural&and&urban&Haiti&based&on&the&first&household&survey&for&


263!DevInfo,!MDG&database&2010:&Haiti.!Available!at!http://www.devinfo.info/mdginfo2010/!264!PAHO,!Health&situation&and&trends&summary:&Haiti!(2007).!Available!at!http://www.paho.org/English/DD/AIS/cp_332.htm!!








!


Figure.15:.Adolescent.Fertility.Rate,.1997.T.2009.


!!

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Figure.16:.Percent.of.15T19.year.old.females.ever.pregnant.or.had.a.child,.2006.



!.

Figure! 16! illustrates! the! stark! contrast! in! adolescent! fertility! between! urban! and! rural! areas,! and!between!women!who!have!been!married!and!those!who!have!never!married.!Adolescent!girls! in!rural!areas! are! approximately! 1.5! times!more! likely! to! have!been!pregnant! than! those! in! urban! areas!—!a!difference! of! 6%! likelihood! of! ever! being! pregnant! during! ages! 15`19.! The! adolescent! fertility! rate! in!rural!areas!(86!per!1,000!girls)!was!far!greater!than!that!in!the!Port`au`Prince!metropolitan!area!(46!per!1,000!girls)270!and!urban!areas!in!general!(69!per!1,000!girls).271!!


271!PAHO,!Health&situation&in&Haiti&before&the&2010&earthquake,!Presentation!at!Haiti!Health!Cluster!(January!2010).!Available!at!http://ec.europa.eu/echo/files/aid/countries/Haiti_paper_01102010.pdf!!

!


One!factor!contributing!to!high!rates!of!adolescent!fertility!in!Haiti! is!the!prevalence!of!child!marriage,!discussed! further! below.! Most! significantly,! as! shown! in! Figure! 16,! adolescent! girls! who! have! ever!married!are!28.5! times!more! likely! to!have!been!pregnant! than! those!who!have!never!married.!Child!marriage! increases! the! probability! of! adolescent! pregnancy,! especially! when! the! girl! is! significantly!younger!than!her!husband,!which!will!be!further!discussed!in!Section!3D.&Child&marriage.!Child!marriage!is!quite!typical!in!Haiti.!In!2006,!only!7.5%!of!married!or!cohabiting!female!youth!in!Haiti!were!the!same!age!or!older!than!their!husband!or!cohabiting!partner!(Figure!17).!In!74.5%!of!couples!involving!female!youth,! the! husband! or! partner! was! less! than! ten! years! older! than! the! female,! while! in! 18.1%,! the!husband!or!partner!was!more! than! ten!years!older.!While! these!proportions!were! roughly!equivalent!between!urban!and!rural!areas,!there!were!small!differences!between!Departments.272!As!noted!by!the!Population!Council,!“The!age!difference!between!partners!—!whether!married!or!not!—!has!implications!for! the! woman’s! ability! to! negotiate! voluntary,! safe,! and! protected! sexual! relations.”273! Young! girls!married!to!considerably!older!men!do!not!have!the!same!ability!to!negotiate!for!contraceptive!use!and!are! more! likely! to! be! sexually! active,! thereby! increasing! their! risk! of! adolescent! pregnancy.274!Furthermore,!when!adolescent!girls!marry,!they!are!also!less!likely!to!continue!with!schooling,!which!is!associated!with!significantly!higher!adolescent!and!lifetime!fertility.275!!








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Figure.17:.Age.difference.between.women.age.15.T.24.and.their.current.partners,.2006.



!!UNICEF!has!noted!that,!in!general,!high!adolescent!fertility!rates!are!associated!with!poverty!and!lack!of!education,!as!individuals!in!these!groups!“often!have!the!least!ability!and!incentive!to!avoid!unplanned!pregnancy.”276! Findings! from!Haiti,!where!poverty! is!widespread! in! rural!areas!and!additional! children!are!perceived!as!necessary!for!their!utility!in!farm!labor,!support!this!proposition.277!As!further!described!in!Section!8E.&Access&to&education&and&barriers&to&enrollment,!educational!opportunities!are!also!closely!related! to! poverty! in! Haiti,! while! inadequate! access! to! education! in! rural! areas! also! prevents! many!adolescents! from! attending! school.! The! inter`related! impacts! of! poverty,! education,! and! access! on!adolescent! fertility! are! highlighted! in! the! 1994`95! Survey! on! Mortality,! Morbidity! and! Utilization! of!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!276!UNICEF,!The&state&of&Latin&American&and&Caribbean&children&2008:&Child&survival!(May!2008).!Available!at!http://www.unicef.org/publications/files/SOLAC_2008_EN_041408.pdf!!

277!T.!T.!Schwartz,!Fewer&men,&more&babies:&Sex,&family&and&fertility&in&Haiti!(Lanham:!Lexington!Books,!2009).!

!


Services! (EMMUS! II),! which! found! that! early! childbearing! is! 3.25! times! more! likely! among! female!teenagers!with!no!education!(26%)!than!among!those!with!secondary!education!(8%).278!!In!a!July!2010!assessment,!Plan!International!noted!anecdotal!reports!provided!by!the!Ministry!of!Health!and!local!service!providers!of!a!dramatic!rise!in!adolescent!pregnancies.!While!Plan!did!not!observe!such!an!increase!in!their!field!visits!to!IDP!camps,!they!concluded!that!the!consistency!of!reports!suggested!that!such!an!increase!was!likely,!but!that!pregnant!adolescents!refrained!from!activities!in!visible!camp!spaces,! further! deepening! their! vulnerability.279! A! January! 30,! 2011! article! by! the! CEO! of! the! UN!Foundation! noted!with! concern! that! fertility! across! Haiti!may! have! tripled! since! the! earthquake,! and!that! there! had! been! a! sharp! increase! in! the! number! of! adolescent! pregnancies! in! IDP! camps.280! If!confirmed,!these!findings!indicate!a!significant!increase!in!risk!for!those!already!chronically!vulnerable,!requiring!the!immediate!attention!of!the!response!community.!!Haitian! women’s! desired! fertility! is! lower! than! their! observed! fertility.281,282! The! 1994`95! EMMUS! II!survey! indicated! that! women! ideally! desired! 3.3! children,! while! men! desired! 3.4.! In! 1995,! then,! the!survey! concluded! that! 34%!of! births!within! the! preceding! five! years!were! not!wanted.283! Similarly,! in!2000,! the!Population!Reference!Bureau! found! that!29.8%!of!pregnancies!were!not!wanted.284!Desired!fertility!was!found!to!increase!with!age.!Those!aged!20`24!wanted!to!have!2.7!children,!while!those!aged!30`34!wanted!3.1!children.285! In!2006,! the!World!Bank!estimated!desired! fertility! to!be!even! lower,!at!2.4!births!per!woman—far! lower!than! its!estimate!of! the!Total!Fertility!Rate! in!that!year,!at!3.66.286!A!2007!study!by!the!Institute!for!Reproductive!Health!found!that!55%!of!women!did!not!want!to!have!any!more!children.287!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!278!M.!Cayemittes,!A.!Rival,!G.!Lerebours,!and!B.!Barrere,!Survey&on&mortality,&morbidity&and&utilization&of&services&



280!K.!Calvin,!Lighting&the&future&for&Haiti’s&women,!UN!Foundation!(January!2011).!Available!at!http://www.unfoundation.org/who`we`are/impact/our`impact/empowering`women`girls/lighting`the`future.html!!






284!Population!Reference!Bureau,!PRB&datafinder:&Haiti.!Available!at!http://www.prb.org/datafinder.aspx!285!Population!Reference!Bureau,!PRB&datafinder:&Haiti.!Available!at!http://www.prb.org/datafinder.aspx!286!World!Bank,!World&development&indicator&database.!Available!at!http://databank.worldbank.org/ddp/home.do?Step=12&id=4&CNO=2!

287!Institute!for!Reproductive!Health,!Awareness&project:&Haiti&country&report,&200552007,!Georgetown!University!(January!2008).!Available!at!http://www.k4health.org/system/files/Haiti%20Country%20Report%202005`2007.pdf!!

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!Unwanted! pregnancies! carry! greater! risks! for! both! the!mother! and! child,! both! because!women!with!unwanted! pregnancies! are! less! likely! to! give! birth! in! the! presence! of! a! skilled! attendant,! and! also!because!they!are!less!likely!to!seek!antenatal!care.!UNICEF!has!estimated!that!the!effective!promotion!of!family! planning! could! reduce! maternal! deaths! by! one! third! in! countries! with! high! birth! rates! and!significantly!reduce!maternity`related!morbidity.288!!While!adolescent`specific!estimates!are!not!available,!comparisons!of!desired!and!actual!lifetime!fertility!suggest!that!a!large!portion!of!the!need!for!family!planning!in!Haiti!remains!unmet.289!Again,!however,!estimates!of! the!extent!of!unmet!need! for! family!planning!vary!by!source.!The!World!Bank!estimated!that! in! 1995,! 44.5%! of! married! women! who! did! not! want! any! more! children! were! not! using!contraception.!In!2000,!this!unmet!demand!had!fallen!to!39.6%,!and!by!2005!had!reached!37.5%.290!In!comparison,! the! UN! Statistics! Division! estimated! that! unmet! need! for! family! planning! was! 47.8%! in!1995,! 39.8%! in! 2000,! and! 37.5%! in! 2006.291,292! A! review! of! data! by! the! Population! Reference! Bureau!found!that!unmet!need!for!family!planning!was!slightly!greater!in!rural!areas!(39%)!than!in!urban!areas!(35%).293!!Demand!for!family!planning!can!be!disaggregated!by!its!purpose,!i.e.,!either!to!limit!fertility!or!to!space!births.!UNICEF!notes!that!spacing!births!by!at! least!two!years! increases!the!chance!of!child!survival.294!According!to!the!UN!Statistics!Division,!17.7%!of!married!women!had!an!unmet!need!for!family!planning!to! space! their! pregnancies! in! 1995.! This! percentage! has! remained! relatively! constant! over! time,!decreasing!to!16%!in!2000,!and!rising!again!to!17%!by!2006.!In!contrast,!unmet!need!for!family!planning!to! limit! total! fertility! has! continued! to! decline! over! the! past! 15! years,! falling! from! 30.1%! in! 1995,! to!23.8%! in! 2000,! to! 20.4%! in! 2006.295! The! literature! does! not! provide! hypotheses! to! explain! the!differential!movement!of!unmet!need!for!limiting!and!spacing!fertility.!!Haiti’s!contraceptive!prevalence!rate!has!increased!from!18%!in!1997!to!32%!in!2009!(Figure!18).296!This!estimate! includes! all! family! planning!methods,! including! “traditional”! methods,! and! coincides! with! a!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!288!UNICEF,!Progress&for&children&number&7:&A&report&card&on&maternal&mortality!(September!2008).!Available!at!http://www.unicef.org/progressforchildren/files/Progress_for_Children`No._7_Lo`Res_082008.pdf!!



291!DevInfo,!MDG&database&2010:&Haiti.!Available!at!http://www.devinfo.info/mdginfo2010/!292!Millennium!Project,!Countdown&to&2015:&2010&Country&profiles:&Haiti!(2010).!Available!at!http://www.countdown2015mnch.org/documents/2010report/Profile`Haiti.pdf!!


295!DevInfo,!MDG&database&2010:&Haiti.!Available!at!http://www.devinfo.info/mdginfo2010/!296!UNICEF,!State&of&the&world’s&children&199752009!(Oxford:!Oxford!University!Press,!1997`2009).!Available!at!http://www.unicef.org/sowc/!!

!


reduction!in!Haiti’s!TFR!over!the!same!period.!The!UN!Statistical!Division!notes!that!among!those!using!any!form!of!contraception,!73.4%!used!a!modern!method!in!2006,!a!minor!increase!from!73.3%!in!1995,!but!a!reduction!from!a!high!of!79.4%!in!2000.297!Only!a!small!percentage!of!those!who!reported!using!contraception! used! condoms.! In! 1995,! condoms! accounted! for! 14.4%! of! all! contraceptives! used,!declining!to!10.3%!in!2000,!before!increasing!to!16.6%!by!2006!(Figure!19).298!!Figure.18:.Contraceptive.prevalence.rate,.1997T2009.

!Data!source:!UNICEF,!State&of&the&world’s&children&199752009!(Oxford:!Oxford!University!Press,!1997`2009).!Available!at!http://www.unicef.org/sowc/!!

!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!297!DevInfo,!MDG&database&2010:&Haiti.!Available!at!http://www.devinfo.info/mdginfo2010/!298!DevInfo,!MDG&database&2010:&Haiti.!Available!at!http://www.devinfo.info/mdginfo2010/!

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Figure.19:.Contraceptive.prevalence.rate:.Total,.modern.methods,.and.condom,.1995T2006.

!Data!source:!DevInfo,!MDG&database&2010:&Haiti.!Available!at!http://www.devinfo.info/mdginfo2010/!!!In! 2006,! use! of! contraception! by! adolescents! was! higher! than! the! national! average.299! However,!contraception! use! varied! by! location! and! marital! status! (Figure! 20).! Those! in! urban! areas! were!approximately! 35%! more! likely! to! use! a! modern! contraceptive! method! than! those! in! rural! areas.!Interestingly,! female! youth! who!were!married! were! 18%!more! likely! to! use! a!modern! contraceptive!method!than!their!never`married!peers.300!!




!


Figure.20:.Percentage.of.females.aged.15T24.who.have.ever/never.used.contraception,.2006.


vulnerable&young&people:&Haiti&2005/06!(2009).!Available!at!http://www.unfpa.org/youth/docs/AdolescentDataGuide_Haiti2005`06.pdf!

!!Similar! to! contraceptive! prevalence! overall,! youth! in! Haiti! reported! higher! use! of! condoms! than! the!national!average!in!2006.301!Overall,!20%!of!female!Haitian!youth!reported!using!a!condom!the!last!time!they!had!sex!(Figure!21).!Condom!use!was!higher!among!those!who!had!never!been!married!than!their!ever`married! peers.! Of! never`married! female! youth,! 36.9%! reported! using! a! condom! at! last! sex,!compared!to!20.3%!of!female!youth!currently!in!union!but!without!a!child,!and!7.2%!in!union!and!with!a!child.!Condom!use!by!female!youth!was!strikingly!higher!in!urban!areas!than!rural!areas,!where!female!


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3.&Demography&


youth!were! less!than!half!as! likely!as!their!urban!peers!to!have!used!a!condom!the! last!time!they!had!sex.!This!was!true!for!all!marital!categories.302!!Figure.21:.Percentage.of.females.aged.15T24.who.used.a.condom.at.last.sex,.2006.



!!Availability!of!condoms!and!other!contraceptive!methods!in!Haiti!has!failed!to!translate!into!high!usage!rates.!The!EMMUS!IV!survey!found!that!the!vast!majority!of!adolescent!men!and!women!knew!where!to!obtain!condoms!but!that!relatively!few!used!one!at!first!sex!(Figure!22).303!



303!Institut!Haitien!de!l’Enfance,!HIV/AIDS&in&Haiti:&Key&findings&of&the&mortality,&morbidity,&and&utilization&of&services&

survey!(2006).!Available!at!http://www.measuredhs.com/pubs/pub_details.cfm?id=767&srchTp=home!

!


!Figure.22:.Knowledge.of.source.for.condoms.and.condom.use.at.first.sex,.2006.


services&survey!(2006).!Available!at!http://www.measuredhs.com/pubs/pub_details.cfm?id=767&srchTp=home!!!

D.&Child&marriage&!Child!marriage!carries!significant!risks,!and!is!a!violation!of!the!rights!of!the!child.304!Young!married!girls!are!more!at!risk!of!sexual!and!gender`based!violence!than!their!unmarried!peers.!2006!EMMUS!IV!data!reveal! that! 25.4%! of! married! girls! age! 15`19! had! experienced! spousal! violence! in! the! 12! months!preceding!the!survey,!with!women!who!married!earlier!facing!higher!risk.305!As!mentioned!above,!child!marriage!may! also! lead! to! adolescent! pregnancy,! which! carries! significantly! higher! risks! for! both! the!woman!and!the!child!than!pregnancies!of!women!in!their!20s.306!Girls!who!marry!may!lack!opportunities!for!social!engagement,!and!face!additional!sexual!and!reproductive!health!risks,307!described!further!in!Sections!3C.&Fertility,!3E.&Mortality,!and!7C.&Sexual&and&reproductive&health.!Married!girls!also!typically!have! limited! control! over! resources,! highly! restricted! mobility,! and! little! or! no! power! in! their! new!households.308!!


305!P.!S.!Pinheiro,!World!report!on!violence!against!children,!United!Nations!secretary`general’s!study!on!violence!against!children,!UN!Doc.!A/61/299!(2006).!Available!at!http://www.unicef.org/violencestudy/reports/SG_violencestudy_en.pdf!!

306!UNICEF,!Progress&for&children&number&7:&A&report&card&on&maternal&mortality!(September!2008).!Available!at!http://www.unicef.org/progressforchildren/files/Progress_for_Children`No._7_Lo`Res_082008.pdf!!




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The!prevalence!of!child!marriage!in!Haiti!has!increased!over!the!past!ten!years.!In!2000,!it!was!estimated!that! 24%! of! young! women! were! married! by! their! 18th! birthday.309! By! 2006,! this! percentage! had!increased! to! 29.9%,!with! rural! areas! reporting! higher! rates! of!married! girls! (32.6%)! than! urban! areas!(27.4%)!(Figure!23).310!Of!greatest!concern!is!the!finding!that!in!2006,!5.6%!of!girls!were!married!before!age!15.!!Figure.23:.Age.at.first.marriage.or.union.for.20T24.year.old.females.(%),.2006.

Source:!Population!Council/UNFPA,!The&adolescent&experience&in5depth:&Using&data&to&identify&and&reach&the&most&


!!Rates!of! illiteracy!are!also!higher!among!those!girls!married!by!age!15!(31.9%)!than!in!their!unmarried!peers!(14.2%)!(Figure!24).!In!both!urban!and!rural!areas,!women!married!before!age!15!were!more!than!twice! as! likely! to! be! illiterate! (19.7%! and! 42.8%,! respectively)! than! their! unmarried! peers! (8.4%! and!20.3%,!respectively).!A!lower!rate!of!school!enrollment!for!married!women!explains!this!finding.!In!2006,!only! 16.4%!of!married! girls! aged! 15`19! and!with! a! child!were! in! school,!while! 59.4%!of!married! girls!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!309!UNICEF,!State&of&the&world’s&children&200452009!(Oxford:!Oxford!University!Press,!2004`2009).!Available!at!http://www.unicef.org/sowc/!!



!


without!a!child!were!in!school,!compared!to!a!rate!of!83.6%!for!those!girls!who!had!never!been!married!and!did!not!have!a!child!(Figure!25).311!In!addition,!age!discrepancies!between!partners,!also!discussed!in!Sections! 3C.& Fertility! and! 3D.& Child& marriage,! play! a! key! role! in! determining! the! educational!opportunities!available!to!married!adolescent!girls.!These!findings!underscore!the!critical!intersection!of!child!marriage,!adolescent! fertility,!education!and! illiteracy,!highlighting! the!necessity! for!holistic!child!protection!responses!aimed!at!reducing!child!marriage.312!!

Figure.24:.Percent.of.15T24.year.old.females.who.are.illiterate,.by.marital.status.at.age.15,.2006.



!!





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Figure.25:.Percent.of.15T19.year.old.females.in.school,.by.marital.and.childbearing.status,.2006.



!!

E.&Mortality&!Haiti! is!periodically!struck!with! large`scale!natural!disasters,!complicating!efforts!both! to!measure!and!respond! to! factors! impacting! mortality.! In! September! 2004,! Hurricane! Jeanne! caused! the! death! of!approximately!5,000!people! in! the!north!and!north`east!of!Haiti,! affected!more! than!300,000!people,!and! caused!property!damage!estimated!at!$250!million.313,314! In!2008,! a! series!of! four!hurricanes!and!one! tropical! storm!seriously!hit!eight!of!Haiti’s! ten!Departments,! killing!800!people,!affecting!800,000!people,!and!destroying!property!and!infrastructure!worth!12%!of!Haiti’s!GDP.315,316!The!12!January!2010!earthquake! had! by! far! the! largest! human! and! infrastructure! impact! of! all! Haiti’s! disasters! in! recent!history:!by!March!2010,!the!Haitian!Government!reported!that!over!220,000!people!had!died!and!over!300,000! were! injured,317! with! an! estimated! 3,000! people! handicapped318! and! 1.5! million! directly!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!313!Oxfam,!Haitians&talk&about&rebuilding&the&country&after&the&January&12,&2010&earthquake!(March!2010).!Available!at!http://www.reliefweb.int/node/351160!!


315!Oxfam,!Haitians&talk&about&rebuilding&the&country&after&the&January&12,&2010&earthquake!(March!2010).!Available!at!http://www.reliefweb.int/node/351160!!

316!ALNAP,!Haiti&earthquake&response:&Context&analysis!(July!2010).!Available!at!http://www.alnap.org/pool/files/haiti`context`analysis`final.pdf!



!


affected.319! Additionally,! critical! health! infrastructure,! programs! and! social! support! networks! were!destroyed!or! interrupted.! The!damage!wrought!by! the!earthquake! therefore!not!only!heightened! the!underlying!mortality!rates!of!the!Haitian!population,!but!also!undermined!the!ability!to!measure!levels,!trends,! and! recovery! efforts.! Relatively! little! disaggregated! mortality! data! has! emerged! since! the!earthquake,!stymieing!timely!efforts!to!assess!Haiti’s!mortality!profile.!Therefore,!the!previous!estimates!cited!below!should!be!used!more!as!a!guide!to!pre`existing!areas!of!need!and!a!baseline!against!which!the! impact! of! the! earthquake! can! be! measured,! rather! than! an! indication! of! the! current! level! of!institutional!and!human!capacity.!!!Life! expectancy! at! birth! in! Haiti! has! significantly! improved! since! 1980,! with! children! born! in! 2009!expected! to! live! roughly! ten!years! longer! than! those!born! in!1980! (Figure!26)—although,!again,! these!estimates! do! not! incorporate! the! effects! of! the! 2008! hurricane! season! nor! the! 2010! earthquake.320!Haitian! life! expectancy! has! continued! to! increase,! on! average,! since! 1960,!when! combined!male! and!female!life!expectancy!at!birth!was!43!years.321!According!to!the!World!Bank,!if!subjected!to!the!current!age`specific!mortality! rates!over! the! course!of! a! lifetime,! a!male! child!born! in!2009!would! live! for! an!average! of! 60.3! years,! while! a! female! child’s! life! expectancy!would! be! 62.6! years—a! female`to`male!ratio!of!1.04.322!UNICEF!estimates!the!female`to`male!life!expectancy!ratio!to!be!slightly!higher,!at!1.06.!The!ratio!of!female!to!male!life!expectancy!has!changed!relatively!little!since!1995,!though!according!to!UNICEF,!the!period!1998`2001!witnessed!a!wider!differentiation!between!the!genders’!life!expectancies!(Figure! 27).323! This! differentiation! is! not! reflected! in! World! Bank! estimates,! which! predict! that! the!percentage!of! females!expected! to! survive! to!age!65! increased! from!46.3%! for! those!born! in!2000! to!57.5%!for!those!born!in!2008,!while!the!probability!for!males!born!in!those!years!increased!from!34.2%!to! 50.8%.324! However,! the! World! Bank! estimates! that! only! a! weighted! average! of! 90%! of! total! life!expectancy!for!either!of!these!cohorts!would!be!spent!with!the!equivalent!of!full!health.325!!






324!UNDP,!Human&development&report!(New!York:!Palgrave!Macmillan,!2001`2007/08).!Available!at!http://hdr.undp.org/en/reports/!!

325!UNDP,!Human&development&report&2007/08:&Fighting&climate&change!(New!York:!Palgrave!Macmillan,!2008).!Available!at!http://hdr.undp.org/en/reports/!!

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Figure.26:.Life.expectancy.at.birth:.Total,.female,.and.male,.1980T2009.


!!

Figure.27:.Female.life.expectancy.as.a.percentage.of.male.life.expectancy,.1995T2009.


!!

!


The! probability! of! children! dying! between! birth! and! age! 20! declined! significantly! between! 1990! and!2009!(Figure!28).326!Overall,!the!probability!of!a!child!dying!before!their!20th!birthday!fell!in!those!years!by! approximately! 40%,! from! 18.17%! to! 11.04%.! This! reduction! was! 3.11%! greater! for! boys,! whose!probability! of! death! before! age! 20! fell! by! 44.66%,! compared!with! the! reduction! in! girl’s!mortality! of!41.55%.!However,! the!observation! that! the!probability!of!death! for!males!and! females!combined!was!lower!than!sex`specific!probabilities!in!2009!raises!concerns!of!data!reliability.!!Figure.28:.Probability.of.death.ages.0T19,.by.sex,.1990T2009.

Probability of

death age 0-19, total

Probability of death age 0-19,

male


female

Ratio of female-to-male

reduction 1990 18.17% 18.22% 18.09% 2000 13.17% 13.48% 12.84% 2009 11.04% 10.08% 10.57%

% reduction 39.23% 44.66% 41.55% 93.04% Data!source:!WHO,!Life&tables&for&WHO&member&states:&Haiti.!Available!at!http://www.who.int/healthinfo/statistics/mortality_life_tables/en/!

!!Haiti’s! neonatal! mortality! rate! (deaths! in! the! first! four! weeks! after! birth! per! 1,000! live! births)! has!significantly! improved! over! the! past! ten! years.! The! State! of! the! World’s! Children! report! states! that!neonatal!mortality!in!Haiti!was!34!deaths!per!1,000!live!births!in!2000,!but!that!this!rate!fell!to!27!deaths!per! 1,000! live! births! by! 2009.327! This! change! represents! a! 20.6%! reduction! between! 2000! and! 2009.!More!recent!estimates!are!not!available.!Analysis!of!mortality!data!from!the!Hôpital!Albert!Schweitzer!(HAS)! in!Artibonite!Department!found!that!35%!of!deaths! in!children!under!five!years!of!age!occurred!during! the! first! month! of! life.! Additionally,! Perry,! Ross,! and! Ferdinand! found! that! among! neonatal!deaths! at! the! HAS,! 27%! occurred! in! the! first! day! after! birth,! and! 80%! in! the! first! ten! days! following!delivery.328!!The!WHO!estimated!that!78%!of!neonatal!deaths! in!Haiti!are!the!result!of!three!causes:!preterm!birth!(29%),!severe!infection!(25%),!and!birth!asphyxia!(24%)!(Figure!29).329!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!326!WHO,!Life&tables&for&WHO&member&states:&Haiti.!Available!at!http://www.who.int/healthinfo/statistics/mortality_life_tables/en/!


328!H.!Perry,!A.!Ross,!and!F.!Ferdinand,!"Cause!of!under`five!mortality!in!rural!Haiti:!Findings!from!the!Hopital!Albert!Schweitzer!service!area,"!Revista&Panamericana&de&Salud&Pública!18!(2005),!pp.!178`186.!

329!WHO,!Mortality&country&fact&sheet&2006:&Haiti!(2007).!

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Figure.29:.Causes.of.neonatal.deaths,.2000.

!Source:!WHO,!Mortality&country&fact&sheet&2006:&Haiti!(2007).!!!Haiti’s! Infant!Mortality!Rate!(IMR)!(deaths!before!the!first!birthday,!per!1,000! live!births)!has!declined!significantly! over! the! past! 20! years,! but! remains! the! highest! in! the! Americas.330! The! World! Bank!attributes! this! high! IMR! to! women’s! low! education! levels,331! while! the! Pan`American! Health!Organization!highlights!the!effects!of!poverty,!deficiencies!in!the!health!care!system,!and!the!impact!of!HIV/AIDS.!UNICEF!estimated!Haiti’s!IMR!to!be!64!per!1,000!live!births!in!2009,!a!reduction!of!9.9%!from!1995! (71! deaths! per! 1,000! live! births),332! 39.0%! from! 1990! (105! deaths! per! 1,000! live! births),333! and!56.8%!from!1970!(148!deaths!per!1,000!live!births)!(Figure!30).334!Haiti’s!IMR!decreased!to!a!low!of!54!deaths! per! 1,000! live! births! in! 2008,! but! increased! in! 2009,! possibly! due! to! the! effects! of! the! 2008!hurricane!season.!Gains!in!IMR!prior!to!2009!were!not!uniform!across!location!or!socio`economic!group:!infant!mortality!was!73.3%!higher!among! the!poorest!quintile!of! the!population! (78!deaths!per!1,000!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!330!IMF,!Haiti:&Poverty&reduction&strategy&paper,!IMF!country!report!No.!08/115!(2008).!Available!at!http://www.imf.org/external/pubs/ft/scr/2008/cr08115.pdf!!



333!DevInfo,!MDG&database&2010:&Haiti.!Available!at!http://www.devinfo.info/mdginfo2010/!334!UNDP,!Human&development&report&2000:&Human&rights&and&human&development!(New!York:!Palgrave!Macmillan,!2000).!Available!at!http://hdr.undp.org/en/reports/!!

!


live!births)!than!among!the!richest!(45!deaths!per!1,000!live!births),335!and!the!IMR!in!Haiti’s!rural!areas!was! 1.4! times! that! in! urban! areas! in! 2007.336! Overall,! Haiti’s! progress! in! reducing! infant!mortality! by!2005!meant!that!it!was!on!track!to!meet!Millennium!Development!Goal!indicator!4.2:!reducing!the!IMR!by!two!thirds!of!the!1990!level!by!2015!(Figure!31).337!However,!the!effects!of!the!2008!hurricane!season!and!the!2010!earthquake!may!have!hindered!Haiti’s!ability!to!meet!this!indicator.338!!Figure.30:.Infant.Mortality.Rate.(IMR),.1995T2009.

!Data!source:!UNICEF,!State&of&the&world’s&children&199752011!(Oxford:!Oxford!University!Press,!1997`2011).!Available!at!http://www.unicef.org/sowc/!

!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!335!UNDP,!Human&development&report&2007/08:&Fighting&climate&change!(New!York:!Palgrave!Macmillan,!2008).!Available!at!http://hdr.undp.org/en/reports/!!

336!UNICEF,!The&state&of&Latin&American&and&Caribbean&children&2008:&Child&survival!(May!2008).!Available!at!http://www.unicef.org/publications/files/SOLAC_2008_EN_041408.pdf!!



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Figure.31:.Progress.towards.MDG.indicator.4.2.(IMR),.1990T2005.

!Source:!IMF,!Haiti:&Poverty&reduction&strategy&paper,!IMF!country!report!No.!09/290!(2009).!Available!at!http://www.imf.org/external/pubs/ft/scr/2009/cr09290.pdf!

!!The!under`five!mortality!rate!(U5MR)!fell!significantly!prior!to!the!2010!earthquake.!Partly!as!a!result!of!the!falling!infant!mortality!rate,!Haiti’s!U5MR!more!than!halved!between!1990!and!2009,!from!a!rate!of!151.2!deaths!per!1,000!live!births!in!1990339,340!to!72!deaths!per!live!births!in!2009341,342—a!reduction!of!52.4%!over!19!years,!and!a!reduction!of!64%!since!1980!(Figure!32).343!While!the!UN!Committee!on!the!Rights!of!the!Child!noted!Haiti’s!performance!in!reducing!its!U5MR,!the!Committee!also!noted!that!60%!of!children!who!survive!until!their!fifth!birthday!do!not!grow!or!develop!normally!after!that!point.344!!Though!Haiti’s!U5MR!reduction!is!impressive,!the!Pan`American!Health!Organization!(PAHO)!observed!in!2007!that!the!achieved!mortality!rate!still!meant!that!one!in!every!12!children!would!die!before!reaching!age!five.345!As!such,!Haiti!still!recorded!the!highest!U5MR!in!the!Latin!America!and!Caribbean!region!in!2006,! leading! Guyana! and! Bolivia! which! had! rates! of! 62! and! 61! deaths! per! 1,000! live! births,!



341!WHO,!Global&health&observatory&database:&Haiti.!Available!at!http://www.who.int/gho/en/!342!UNESCO,!Data&center:&Custom&tables:&Haiti.!Available!at!http://stats.uis.unesco.org/unesco/TableViewer/document.aspx?ReportId=136&IF_Language=eng&BR_Topic=0!




!


respectively.346!Despite!its!progress,!Haiti!was!not!on!track!to!meet!MDG!4:!reducing!the!U5MR!by!two`thirds!by!2015!(Figure!33).347!Additionally,!the!U.S.!Census!Bureau!estimates!that!the!2010!earthquake!increased!the!incidence!of!under`five!mortality,!raising!its!estimate!to!181!deaths!per!1,000!live!births.348!In!the!wake!of!the!earthquake,!the!WHO!reported!that!!!

(N)one!of!the!mortality!indicators!found!in!CE`DAT!exceed!the!WHO!emergency!threshold!levels!of!1!death!per!10,000!persons!per!day!(CMR)!and!2!deaths!per!10,000!persons!per!day!(U5MR).!However,! the! Sphere! guidelines! place! regional! emergency! thresholds! at! 0.3! (CMR)! and! 0.4!(U5MR)! deaths! per! 10,000! persons! per! day,! which! are! approximately! double! the! regional!baselines!for!CMR!and!U5MR!in!Latin!America!and!the!Caribbean.!

!Under`five!mortality!differentially!affects!sub`populations,!especially!those!of!different!socio`economic!groups,!urban/rural!location,!and!mother’s!education!quintile!(Figure!34).!Children!in!the!lowest!income!quintile!were!50.5%!more! likely! to!die!before!age! five! than! those! in! the! top! income!quintile! in!2000.!Children!under!five!in!rural!areas!were!33.0%!more!likely!to!die!than!their!urban!peers.!Underscoring!the!impact! of!women’s! education! on! reducing! under`five!mortality,! children!whose!mothers!were! in! the!lowest!education!quintile!were!twice!as!likely!to!die!before!their!fifth!birthday!as!those!whose!mothers!were!in!the!highest!education!quintile.349!!According!to!PAHO,!tuberculosis,!diarrheal!diseases,!malnutrition,!HIV/AIDS,!and!malaria!were!the!five!leading!causes!of!death!in!2007.350!In!contrast,!the!WHO!Global!Health!Observatory!database!states!that!the!five!leading!causes!of!under`five!death!in!2008!were!pneumonia!(22%),!diarrhea!(22%),!prematurity!(10%),!birth!asphyxia!(9%),!and!neonatal!sepsis!(5%),!with!“other!causes”!accounting!for!24%!of!deaths!in! this! age! group.351! Discrepancies! between! these! estimates! may! be! explained! by! the! exclusion! of!neonatal!and!infant!causes!of!death!by!PAHO.!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!346!UNICEF,!The&state&of&Latin&American&and&Caribbean&children&2008:&Child&survival!(May!2008).!Available!at!http://www.unicef.org/publications/files/SOLAC_2008_EN_041408.pdf!!



349!WHO,!Mortality&country&fact&sheet&2006:&Haiti!(2007).!350!PAHO,!Health&in&the&Americas&2007:&Volume&II&–&countries:&Haiti!(2007).!Available!at!http://www.paho.org/hia/archivosvol2/paisesing/Haiti%20English.pdf!!

351!WHO,!Global&health&observatory&database:&Haiti.!Available!at!http://www.who.int/gho/en/!

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Figure.32:.UnderT5.Mortality.Rate.(U5MR),.1980T2009.

!Data!sources:!World!Bank,!World&development&indicator&database.!Available!at!http://databank.worldbank.org/ddp/home.do?Step=12&id=4&CNO=2!and!WHO,!Global&health&observatory&database:&Haiti.!Available!at!http://www.who.int/gho/en/!

!!

Figure.33:.Progress.towards.MDG.4.(U5MR),.1990T2005.


!!

!


Figure.34:.Disaggregation.of.U5MR.by.socioTeconomic.group,.sex,.urban/rural.status,.and.mother's.education,.2000.

!Source:!WHO,!Mortality&country&fact&sheet&2006:&Haiti!(2007).!!!!According!to!the!WHO,!mortality!among!children!age!5`9!has!almost!halved!during!the!past!20!years.!In!1990,! children! surviving! to! their! fifth! birthday! experienced! a! 1.56%! likelihood! of! mortality! before!reaching! age! ten! (Figure! 35).! The! probability! of! mortality! in! these! ages! was! greater! for! young! girls!(1.64%)!than!young!boys!(1.49%).!By!2009,!the!probability!of!death! in!the!5`9!age!group!had!fallen!by!44.86%!to!0.86%!overall.!Young!girls!continued!to!face!a!greater!risk!of!death!during!these!years!(0.81%)!than! young! boys! (0.76%).! However,! young! girls’! probability! of! mortality! in! this! age! group! fell!proportionally!more!(50.31%)!than!that!for!young!boys!(48.66%)!over!the!period!1990`2009.352!!!!!!!!!


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Figure.35:.Probability.of.death.age.5T9,.by.sex,.1990T2009.


total


male


female


reduction 1990 1.56% 1.49% 1.64% 2000 1.04% 1.04% 1.04% 2009 0.86% 0.76% 0.81%


!!In! 2007,! the!WHO! reported! that! 27%! of! recorded! deaths! in! the! 5`9! age! group! were! attributable! to!infectious! and! parasitic! diseases.! Tuberculosis,! diarrheal! disease,!malnutrition,! HIV/AIDS,! and!malaria!were! the! leading!causes!of!death,! similar! to! the!0`4!age!group.!Significantly,!8%!of!deaths!among!5`9!year`olds!were!from!external!causes:!data!from!2000!revealed!that!boys!were!more!likely!to!be!victims!of!traffic!accidents!and!girls!more!often!victims!of!accidents!in!the!home.!!In! 2009,! Haitian! adolescents! (age! 10`19)! had! a! 1.41%! chance! of! dying! between! their! 10th! and! 20th!birthdays! (Figure! 36).! The! probability! was! higher! for! adolescent! girls! (1.28%)! than! adolescent! boys!(1.15%).!These!statistics!are!consistent!with!the!situation!in!1990,!when!adolescent!girls!were!found!to!have!a!higher!(2.56%)!chance!of!dying!than!adolescent!boys!(1.56%).!While!adolescent!boys’!probability!of! death! moderately! declined! between! 1990! and! 2009! (26.06%! reduction),! the! risk! of! death! for!adolescent!girls!fell!by!almost!half!(49.89%).353!!Figure.36:.Probability.of.death.age.10T19,.by.sex,.1990T2009.

Probability of



male


female


reduction 1990 2.06% 1.56% 2.56% 2000 1.52% 1.43% 1.61% 2009 1.41% 1.15% 1.28%


!!The! reduction! in! the! probability! of! death! for! adolescent! girls! was! greater! in! the! 15`19! age! group!(55.33%)! than! the!10`14!age! group! (41.91%)!over! the!period!1990`2009! (Figure!37!and! Figure!38).! In!


!


contrast,! adolescent! boys’! probability! of! death! experienced! a! greater! decline! in! the! 10`14! age! group!(30.38%)!than!the!15`19!age!group!(21.91%).354!!Figure.37:.Probability.of.death.age.10T14,.by.sex,.1990T2009.

Probability of



male


female


reduction 1990 0.90% 0.78% 1.01% 2000 0.63% 0.62% 0.65% 2009 0.63% 0.54% 0.59%


!!Figure.38:.Probability.of.death.age.15T19,.by.sex,.1990T2009.

Probability of death age 15-

19, total


male


female


reduction 1990 1.17% 0.78% 1.56% 2000 0.89% 0.82% 0.97% 2009 0.78% 0.61% 0.70%


!!The! mortality! profile! of! adolescent! Haitians! differs! significantly! from! their! younger! peers,! as! non`communicable!factors!play!an!increasingly!important!role!in!the!older!group.!In!2007!PAHO!stated!that!the! six! leading! causes! of! death! among! this! age! group! were! HIV/AIDS,! physical! assault,! accidents,!tuberculosis,!typhoid,!and!pregnancy`related!factors!(maternal!mortality).355!In!2003,!6%!of!all!deaths!in!the!15`19!age!group!were!connected!with!assaults,356!while!5.8%!were!attributed!to!HIV/AIDS.357!!!Maternal!mortality!remains!a!major!concern!in!Haiti,!both!because!adolescent!fertility!carries!a!greater!risk! of! death,! and! because!maternal! death! has! a! negative! impact! on! child! survival! and! development.!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!354!WHO,!Life&tables&for&WHO&member&states:&Haiti.!Available!at!http://www.who.int/healthinfo/statistics/mortality_life_tables/en/!




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Women! in! Haiti! have! a! 1! in! 44! (2.3%)! probability! of! dying! from!maternity`related! causes! over! their!lifetime.358! Haiti’s! reported! Maternal! Mortality! Ratio! (number! of! maternal! deaths! per! 100,000! live!births)! is! consistently! below! estimates! by! non`governmental! and! inter`governmental! organizations,!although!these!estimates!recently!converged!following!the!2005`2006!EMMUS!IV!survey!(Figure!39).!In!2007,!UNICEF!estimated! that!Haiti’s!MMR!was!670!maternal!deaths!per!100,000! live!births,!while! the!Haitian!Government!reports!a!MMR!of!630.359!These!estimates!are!considerably!higher!that!the!results!of! EMMUS!surveys! II! and! III,!which! reported!MMRs!of!523!and!457!maternal!deaths!per!100,000! live!births,! respectively.360! By! International! Monetary! Fund! (IMF)! estimates,! Haiti! will! fall! far! short! of!meeting!its!MDG!target!of!114!maternal!deaths!per!100,000!live!births!by!2015!(Figure!40).!!Figure.39:.Maternal.Mortality.Ratio.(MMR):.Reported.and.adjusted,.1995T2007.


!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!358!Population!Reference!Bureau,!PRB&datafinder:&Haiti.!Available!at!http://www.prb.org/datafinder.aspx!359!UNICEF,!State&of&the&world’s&children&2007!(Oxford:!Oxford!University!Press,!2007).!Available!at!http://www.unicef.org/sowc/!!


!


Figure.40:.Progress.towards.MDG.5.A.(MMR),.1990T2005.


!!Analysis!of!maternal!mortality! causes!by!PAHO! in!2003! indicate! that! childbirth! complications,! such!as!hemorrhage,! are! the! leading! causes! of! maternal! death! (29%),! with! hypertension! and! eclampsia!accounting!for!26%!of!these!deaths.!PAHO!notes!with!concern!that!abortion!was! implicated! in!13%!of!maternal!deaths.361!!High!adolescent!birth!rates!are!also!a!cause!for!concern!among!Haitian!adolescent!girls,!and!contribute!significantly!to!the!Maternal!Mortality!Ratio.!Adolescent!childbirth!carries!additional!risks,!as!these!girls!may!be!less!likely!to!give!birth!in!the!presence!of!a!skilled!attendant,!lack!necessary!reproductive!health!information,!and!may!not!be!physiologically!mature.!Adolescent!mothers!younger!than!15!are!five!times!more!likely!to!die!during!childbirth!than!women!in!their!twenties.362!!Access! to!modern!contraceptive!methods,!health! services,! and!women’s!education!are!key!protective!factors!against!maternal!mortality.!Prevalence!of!medically! assisted! childbirth!has! remained! steady!at!24%! over! the! past! decade.363! Increasing! coverage! should! reduce! the! Maternal! Mortality! Ratio.!Additionally,! increasing! contraceptive! prevalence! (discussed! in! Section! 3C.& Fertility,! above)! should!




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contribute! to! a! decline! in! maternal! mortality,! especially! those! occurring! as! a! result! of! unsafe!abortions.364!Women’s!education!is!also!a!key!factor!in!reducing!maternal!mortality.!UNICEF!states!that!“for! each! additional! year! of! education! achieved! by! 1,000! women,! two! maternal! deaths! will! be!prevented.”365!Women’s!education!also!increases!negotiating!power!with!partners,!including!the!ability!to!make!decisions!affecting!their!health.366!!In!addition,!maternal!mortality! is!negatively!associated!with!ensuring!the!protection!and!development!of!the!child.!Anderson!et&al.!found!that!families!experiencing!a!maternal!death!have!55.0%!greater!odds!of!losing!a!child!under!12,!whereas!the!death!of!other!family!members!does!not!increase!these!odds.367!Children!without!parental!care!also!face!increased!risk!of!other!negative!protection!outcomes,!discussed!in!Section!5D.&Children&without&parental& care,!highlighting! the!primacy!of! reducing!maternal!mortality!for!the!protection!of!Haiti’s!children.!!!

F.&Family&structure&!This!section!will!discuss!household!size!and!composition!in!Haiti!before!and!after!the!January!12,!2010!earthquake,! the! broad! range! of! unions! (marriage! and! informal)! among! the! Haitian! population,! and!gender!and!age!roles!within!households.!An!examination!of!orphans,!foster!children,!and!the!effects!of!a!lack!of!parental!care!in!Haiti!is!presented!in!Section!5D.&Children&without&parental&care.!!In!2001,!Haiti!had!an!average!household!size!of!approximately!4.6!people,!with!significant!differences!among! Departments! and! socioèconomic! groups! (Figure! 41).! Those! in! the! non`poor! socioèconomic!category!exhibited!significantly!fewer!household!members368!(3.6!per!household)!than!in!poor!(4.9!per!household)!and!indigent!(5.1!per!household)!households.!The!EMMUS!IV!(2005`2006)!survey!indicated!an! increase! in! average! household! size,! to! 4.9! members,! with! persistent! differences! among! different!Departments!and!socioèconomic!groups.369!However,!this!density! is!similar!to!the!EMMUS!II!estimate!from! 1994`1995! of! five! members! per! household,! indicating! that! the! decrease! in! household! size!




367!F.!W.!Anderson,!S.!U.!Morton,!S.!Naik,!and!B.!Gebrian,!“Maternal!mortality!and!consequences!on!infant!and!child!survival!in!rural!Haiti,”!Journal&of&Maternal&and&Child&Health!11/4!(2007),!pp.!395`401.!




!


exhibited! in!2001!may!be!the!result!of!sample!error!rather!than!a!true!reduction!(standard!deviations!reported!in!parentheses!for!estimates!in!Figure!41).370!!Figure.41:.Average.household.size,.by.income.group.and.Department,.2001.


for&Haiti,!World!Bank!Sustainable!Development!Division!(March!2008).!Available!at!http://go.worldbank.org/AE6TJ7EPY0!

!!A!2009!assessment!by!the!PanÀmerican!Development!Foundation!(PADF)!found!a!significant!difference!between! the!national! average!household! size! and! those! in! troubled!urban!neighborhoods! in! Portàu`Prince,!Cap`Haïtien,!Gonaïves,!Saint`Marc,!and!Petit`Gôave.!In!these!areas,!average!household!size!was!6.3! members,! compared! to! the! 2005`2006! EMMUS! IV! national! estimate! of! 4.9! (Figure! 42).371! This!difference!is!consistent!with!the!assertion!that!household!size!is!associated!with!socioèconomic!status,!as! the! surveyed! troubled! neighborhoods! are! generally! of! lower! socioèconomic! status! (although! the!PADF!estimates!remain!higher!than!any!point!estimates!from!2001).!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!370!M.!Cayemittes,!A.!Rival,!G.!Lerebours,!and!B.!Barrere,!Survey&on&mortality,&morbidity&and&utilization&of&services&



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Figure.42:.Household.size.in.troubled.neighborhoods.in.PortTauTPrince,.CapTHaïtien,.Gonaïves,.SaintTMarc.and.PetitTGôave,.2009.

CITY. Average. N.PortTauTPrince. 6.2! 777!CapTHaitian. 6.2! 267!Gonaïves. 6.9! 166!SaintTMarc. 6.5! 123!PetitTGoâve. 5.9! 120!Total. 6.3! 1453!

Source:!G.!R.!Smucker,!Y.!F.!Pierre,!and!J.!F.!Tardieu,!Lost&childhoods&in&Haiti:&Quantifying&child&trafficking,&restavèks,&&&victims&of&violence,!Pan!American!Development!Foundation!Protecting!Human!Rights!Project!(November!2009).!Available!at!http://www.crin.org/docs/Haiti_lost_childhoods.pdf!

!!The! destruction! caused! by! the! January! 2010! earthquake! forced! many! individuals! and! families! to!relocate.!This!was!due!both!to!the!damage!caused!by!the!earthquake!to!previous!living!quarters,!and!to!fear! of! living! in! permanent! structures! given! the! possibility! of! aftershocks.! As! many! households!effectively!doubled!in!size,!their!short`,!medium`!and!long`term!needs!remain!a!cause!for!concern,!even!as!those!displaced!return!to!their!pre`earthquake!residences.372!!A! rapid! assessment! of! programming! areas! in! La! Gonâve,! Plateau! Central,! and! Nord! and! Sud!Departments!by!World!Vision!showed!significant!growth!in!household!size!as!a!result!of!IDP!movement!(Figure! 43).! In! Sud! Department,! household! size! more! than! doubled! 2001! estimates,! from! 4.7! per!household!to!9.8!per!household,!placing!a!significant!strain!on!households.!Increased!size!was!reported!by! 48%! of! households! in! La! Gonâve! and! 36%! of! households! in! Plateau! Central.! Nord! Department!exhibited! the! smallest! percentage! (27%)! of! households! reporting! an! increase! in! size! following! the!earthquake.! According! to! World! Vision,! almost! 100%! of! household! growth! in! rural! areas! was!attributable! to! IDPs! from! the! Port`au`Prince! metropolitan! area,! motivated! by! either! the! collapse! of!houses!or! the! lack!of!available!employment!opportunities! in! former!areas!of! residence.373! In!contrast,!Catholic!Relief!Services!states!that!78%!of!respondents!in!Sud!Department!reported!hosting!an!average!of! 5.6! IDPs! in! their! household!–! a! figure! far! greater! than!estimates! compiled!by!World!Vision.374! This!discrepancy! may! be! explained! by! the! different! survey! periods,! as! World! Vision! conducted! their!assessment!from!3`6!February,!whereas!Catholic!Relief!Services!assessed!the!time!period!12!February`1!March,! when!more! people! may! have! had! the! opportunity! to! reestablish! connections! with! extended!family!and!migrate!to!other!Departments.!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!372!IFRC,!Haiti&recovery&assessment:&Volume&1&–&Synthesis&report!(March!2010).!Available!at!http://haiti.humanitarianresponse.info/LinkClick.aspx?fileticket=jNS41RGePVg%3d&tabid=149&mid=1043!!


374!UN!OCHA!Haiti,!Haiti:&Humanitarian&assessment&key&findings&No.&2,!29!March!2010!(March!2010).!Available!at!http://groups.google.com/group/assessmentshaiti/browse_thread/thread/71f3f127213f7a06!!

!


Figure.43:.Average.household.size.in.World.Vision.operational.areas.in.La.Gonâve,.Plateau.Central,.and.Nord.and.Sud.Departments.following.the.January.2010.earthquake,.March.2010.

!Source:!World!Vision,!Rapid&assessment&report:&Haiti&earthquake&response!(March!2010).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/Full_Report_583.pdf!

!!Studies! indicate! that! children!under!age!15!accounted! for!a!greater! share!of!household!population! in!rural! than! in! urban! areas! and! in! poor! versus! non`poor! households! before! the! 2010! earthquake.375!Accordingly,! households! in! rural! areas! and! in! low! socio`economic! groups! demonstrate! a! larger!dependency!ratio,!reducing!their!potential!ability!to!provide!for!their!children’s!needs!and!complicating!poverty! reduction! strategies.! Schwartz! believes! that! children’s! labor! utility! explains!why! fertility! rates!have!not!declined!as!significantly!in!rural!areas!as!they!have!in!urban!areas.!In!addition!to!their!utility!in!agricultural! work,! children! often! conduct! small,! time`consuming! tasks! that! free! adults! to! engage! in!gardening!and!commerce.!As!such,!households!in!rural!areas!may!desire,!or,!at!least,!can!justify,!a!larger!percentage!of!children!per!household.376!!The!World!Bank!estimates!that!urban!and!rural!extremely!poor!households!have!more!family!members!under!age!15!than!do!non`poor!households.!In!2007,!rural,!“extremely!poor”!households!had!an!average!of! 2.2! children! under! age! 15,! while! urban! extremely! poor! households! had! an! average! of! 1.7.! In!comparison,!during!approximately!the!same!time!period,!rural!and!urban!non`poor!households!had!an!average!of!0.9!and!1.2!children!under!age!15,! indicating!a!strong!association!between!poverty!and!the!child!share!of!households.377,378! It! is!unclear!whether!this!association!is!directly!causative!or!not—poor!households!may!have!more! children!due! to! attitudes!or! conditions! that!happen! to!be!more! common!among!less!affluent!populations!such!as!a!lack!of!access!to!contraception!or!poor!female!empowerment,!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!375!World!Bank,!Social&resilience&and&state&fragility&in&Haiti:&A&country&social&analysis,!Caribbean!Country!Management!Unit,!Report!no.!36069`HT!(April!2006).!Available!at!http://siteresources.worldbank.org/SOCIALANALYSIS/1104894`1115795935771/20938696/Haiti_CSA.pdf!!

376!T.!T.!Schwartz,!Fewer&men,&more&babies:&Sex,&family&and&fertility&in&Haiti!(Lanham:!Lexington!Books,!2009).!377!World!Bank,!Social&resilience&and&state&fragility&in&Haiti:&A&country&social&analysis,!Caribbean!Country!Management!Unit,!Report!no.!36069`HT!(April!2006).!Available!at!http://siteresources.worldbank.org/SOCIALANALYSIS/1104894`1115795935771/20938696/Haiti_CSA.pdf!!



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or!they!may!desire!more!children!due!to!perceptions!that!children’s! labor!has!utility!and!that!children!represent!an!investment!in!parents’!retirement.!It!is!also!unclear!what!effect!the!earthquake!has!had!on!household! composition,!especially!given!widespread! internal!migration!and! recourse! to! fosterage!and!the!“restavek”!phenomenon!(see!Section!9A.&Children&in&domestic&service&and&servitude).!!Destruction! of! residential! facilities! during! the! January! 2010! earthquake! has! led! to! an! unsustainable!situation! of!multiple! families! residing! in! the! same! shelter.! Very! little! data! exist! on! the! prevalence! of!multiple`family! households! prior! to! the! earthquake,! although! some! observers! have! noted! that! this!phenomenon! is!more!prevalent! in!major!cities.379!The!most!common!reasons!given!for!multiple`family!households!before!the!earthquake!were!economic!concerns,!which!led!to!the!migration!of!one!or!more!family!members,!or! the!death!of!a!child’s!parents! leading!to! their!placement! in!another!household.380!Postèarthquake,!the!most!common!explanation!has!been!the!destruction!of!previous!residences,!which!led! to! a! significant! prevalence! of!multiple`family! households,! either!within! or! outside! IDP! camps.! An!assessment!by!the!Massachusetts! Institute!of!Technology!Lincoln!Laboratory!and!Partners! in!Health! in!April! 2010! found! that! almost! 75%! of! shelters! in! Gonaïves,! 50%! of! shelters! in! Jeremie,! and! 70%! of!shelters!in!Portàu`Prince!contained!six!or!more!families.!The!vast!majority!of!shelters!in!surveyed!areas!housed!three!or!more!families,!while!a!very!small!percentage!contained!only!one!or!two.381!As!IDPs!have!relocated! to! temporary! and! permanent! shelters! constructed! during! the! earthquake! response,! and!others!have!found!alternative!housing,!it!is!likely!that!the!proportion!of!households!containing!multiple!families!has!decreased.!However,!no!national!study!has!been!undertaken!to!test!this!hypothesis.!!Two! additional! features! of! Haitian! households! merit! mention:! the! importance! of! both! the! extended!family!and!the!lakou!system,!especially!in!rural!Haiti.!Extended!family!networks!are!extremely!important!in! Haiti,! whether! to! access! a! job,! share! household! risk,! or! respond! in! times! of! crisis.! When! parents!migrate,! they! often! entrust! their! children! to! extended! family! before! those! outside! the! family.382! As!Justensen!and!Verner!note,!the!nuclear!family!is!not!a!common!phenomenon!in!Haiti,!where!households!will! typically!be! comprised!of! three!or!more!generations.383,384!Moreover,! in! rural!Haiti! especially,! the!role! of! the! lakou! system! has! significant! importance! to! child! protection! and! development.! A! lakou! is!typically!a! small!peasant!village!of!4! to!100!households!constituted!by!a! large!extended! family! that! is!generally!conjugally!or!ancestrally! related!to! the!descendants!of! the! first!owner!of! farmland.385,386!The!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!379!PAHO,!Health&in&the&Americas&2007:&Volume&II&–&countries:&Haiti!(2007).!Available!at!http://www.paho.org/hia/archivosvol2/paisesing/Haiti%20English.pdf!!


381!UN!OCHA!Haiti,!Haiti:&Humanitarian&assessment&key&findings&No.&4&(April!2010).!382!Cultural!Consultation!Service,!Mental&health&in&Haiti:&A&literature&review!(February!2010).!Available!at!http://www.state.nj.us/humanservices/dmhs/disaster/MH_in_Haiti%20_Literature_Review.pdf!!

383!M.!Justesen!and!D.!Verner,!Factors&impacting&youth&development&in&Haiti,!World!Bank!policy!research!working!paper!No.!4110!(2007).!Available!at!http://ddpèxt.worldbank.org/EdStats/HTIprwp07.pdf!!

384!S.!C.!Wortham,!“The!young!child!and!social!relationships!in!developing!countries,”!in!M.!R.!Jalongo!(ed),!Enduring&bonds:&the&significance&of&interpersonal&relationships&in&young&children’s&lives!(Indiana:!Springer,!2007).!

385!J.!M.!Dash,!Culture&and&customs&of&Haiti!(Westport,!CT:!Greenwood!Press,!2001).!386!S.!Larose,!“The!Haitian!lakou:!Land,!family!and!ritual,”!in!A.!F.!Marks!and!R.!A.!Romer!(eds),!Family&and&kinship&in&

middle&America&and&the&Caribbean!(Leiden:!University!of!the!Netherlands!Antilles,!1976).!

!


lakou!system!is!central!to!the!organization!of!collective!labor!(the!coumbite)!at!harvest!time387!and!has!evolved!in!response!to!traditional!inheritance!practices!whereby!descendants!each!receive!a!portion!of!the!land!owned!by!their!parents!upon!their!parents’!death388—resulting!in!decreased!per!capita!holdings!with!each!successive!generation.389!Edmond,!Randolph!and!Richard!state!that!the!lakou!system!provides!“financial!and!emotional!support!that!sometimes!reduces!family!hardship!and!provides!a!buffer!for!daily!stressors—but!the!ability!to!provide!support!is!compromised!by!poverty.”390!In!the!lakou!system,!several!women! cooperatively! care! for! and! supervise! children,! in! contrast! to! the! nuclear! model! common! in!Western!countries.!A!2007!survey!of!a!small!rural!community!in!Leogane!found!that!most!mothers!(81%)!had!resided!for!more!than!ten!years!in!their!lakou,!and!nearly!two`thirds!(65%)!had!both!kin!and!blood!relatives!who! resided! in! the! same! lakou.!While! the! lakou! system! has! been! progressively! replaced! by!household`centric! child`rearing! strategies! in! recent! years,! it! remains! an! important! consideration! in!Haiti’s!rural!child!protection!and!development!strategies.391!!Partnership! unions! in! Haiti! vary! considerably! in! terms! of! legal! status! and! stability,! with! significant!impacts! on! the! children! of! such! unions.392! There! are! five! general! levels! of! unions,! though! some!may!overlap.! In! decreasing! level! of! stability,! these! are:! 1)!Marye! (legal! marriage),! 2)! plase! (“setting! up! a!household”),!3)!vivavek!and!menaj!(“living!with!someone”!and!“living!as!a!pair,”!respectively),!4)!reman!and! fyanse! (“lover”! and! “engaged,”! respectively),! and! 5)! antente,! flirte! and!wik’en! (“getting! along,”!“flirt,”!and!“weekend,”!respectively).393!!Marye!and!plase!are!the!most!popular!unions!in!Haiti.!Legal!marriage!(marye)&is!the!most!coveted!type!of! union! but! the! second`most! common! due! to! the! cost! of! festivities.394,395! Plase! is! the! second!most!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!387!J.!M.!Dash,!Culture&and&customs&of&Haiti!(Westport,!CT:!Greenwood!Press,!2001).!388!World!Bank,!A&review&of&gender&issues&in&the&Dominican&Republic,&Haiti&and&Jamaica,!Report!No.!21866`LAC!(2002).!Available!at!http://www`wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2003/03/22/000094946_03030704005682/Rendered/PDF/multi0page.pdf!!

389!S.!Larose,!“The!Haitian!lakou:!Land,!family!and!ritual,”!in!A.!F.!Marks!and!R.!A.!Romer!(eds),!Family&and&kinship&in&

middle&America&and&the&Caribbean!(Leiden:!University!of!the!Netherlands!Antilles,!1976).!390!Y.!M.!Edmond,!S.!M.!Randolph,!and!G.!L.!Richard,!“The!lakou!system:!A!cultural,!ecological!analysis!of!mothering!in!rural!Haiti,”!Journal&of&Pan&African&Studies!2/1!(2007),!pp.!19`32.!

391!Y.!M.!Edmond,!S.!M.!Randolph,!and!G.!L.!Richard,!“The!lakou!system:!A!cultural,!ecological!analysis!of!mothering!in!rural!Haiti,”!Journal&of&Pan&African&Studies!2/1!(2007),!pp.!19`32.!


393!G.!Maynard`Tucker,!“Haiti:!Unions,!fertility!and!the!quest!for!survival,”!Social&Science&&&Medicine!43/9!(1996),!pp.!1379`1387.!


395!M.!J.!N’Zengou`Tayo,!“Fanm!se!potomitan:!Haitian!woman!is!the!pillar!of!society,”!Feminist&Review!59!(1998),!pp.!118`142.!!

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3.&Demography&


preferred!type!of!union!and!the!most!commonly!practiced,!especially!in!the!countryside396,397!(estimated!at! 51.3%!of!women!attending! antenatal! services! at!Hospital! Albert! Schweitzer,! Artibonite! in! 2000).398!Plasage&generally! involves! cohabitation,! and!may!be! as! stable! as! legal!marriage,! although! it! does!not!carry!the!same!legal!weight!as!marriage.399!Under!a!plase!relationship,!a!man!may!have!more!than!one!common`law!wife!but! is!expected!to!financially!provide!for!each!wife!and!any!children!borne!of!those!unions.400! In! 2007,! Justensen! and! Verner! stated! that! approximately! 8%! of! “married”!men! have!more!than! one!wife.401!Marye&and!plase! unions! are! generally! characterized! by! a!more! steady! income! than!other! types!of! unions.402! The!World!Bank!also!hypothesizes! that! another! reason! for! the!popularity!of!plase!unions!may!be!men’s!reluctance!to!disinherit!prospective!children!born!with!other!women!outside!of!a!legal!marriage!(marye).403!Attributing!paternity!is!a!critical!social!and!filial!factor!in!Haitian!society,!and!by! law!and!custom,!a!married!(marye)!man’s!children!with!other!women!may!not!be!his!heirs.!As!such,!children!born!of!unions!other!than!legal!marriage!may!not!have!many!of!the!same!rights!as!those!born! from!marye! unions,! including! the! right! to! inheritance!and,! in! some!cases,! the! right! to! know! the!identity!of!their!father.404!!Vivavek! and! menaj! unions! are! less! stable! than! marye! and! plase! and! may! or! may! not! involve!cohabitation;! however,! they! are!more! stable! than! visiting! sexual! relationships.405!Vivavek! and!menaj!unions!are!two!of!the!three!most!widespread!unions!in!rural!areas,!with!remen!unions!also!prevalent,406!while!vivavek!unions!are!the!third!most!common!form!of!union!nationally.407!As!they!are!less!stable!than!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!396!World!Bank,!A&review&of&gender&issues&in&the&Dominican&Republic,&Haiti&and&Jamaica,!Report!No.!21866`LAC!(2002).!Available!at!http://www`wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2003/03/22/000094946_03030704005682/Rendered/PDF/multi0page.pdf!!

397!J.!M.!Dash,!Culture&and&customs&of&Haiti!(Westport,!CT:!Greenwood!Press,!2001).!398!D.!W.!Fitzgerald,!F.!Behets,!A.!Caliendo!A,!et!al.,!“Economic!hardship!and!sexually!transmitted!diseases!in!Haiti’s!rural!Artibonite!Valley,”!American&Journal&of&Tropical&Medicine&and&Hygiene!62/4!(2000),!pp.!496`501.!









407!World!Bank,!A&review&of&gender&issues&in&the&Dominican&Republic,&Haiti&and&Jamaica,!Report!No.!21866`LAC!(2002).!Available!at!http://www`

!


marye!and!plase!unions,!issues!arise!when!a!father!refuses!to!provide!financially!for!the!children!borne!of!the!union.408!!Remen!and! fyanse! relationships!are!sexual! relationships! that!are!most!prevalent!among!young!people!and!generally!do!not! involve!cohabitation.!Fyanse! relationships!are!more!common! in!urban!areas!and!are!generally!practiced!by!wealthier!individuals.!They!may!or!may!not!lead!to!plase!unions.409!!!Antente,!flirte,!and!wik’en!are!the!most!casual!sexual!relationships!and!are!generally!unstable.410!!The!1994`1995!EMMUS!II!survey!indicated!that!32%!of!women!and!43%!of!men!aged!15`49!were!single.!In! this! age!group!46%!of!women!and!44%!of!men! reported!being! in! a! relationship!with! cohabitation,!while!12%!and!7%!of!women!and!men,!respectively,!reported!being!in!unions!without!cohabitation.411!!Gender!roles!play!an!important!part!in!social!and!familial!organization!in!Haiti.!The!Cultural!consultation!service!recently!noted!that!“women!are!responsible!for!market!transactions,!management!of!the!family!budget,! food! preparation,! and! care! of! the! children.”412,413! In! addition,! rural! women! fetch! water! and!assist! in! agricultural! activities! at! harvest! time.414! In! contrast,! men! are! generally! responsible! for!agriculture,!repair!and!maintenance!of!the!home,!and!providing!for!the!family.415!These!responsibilities!have!shifted!in!the!course!of!the!past!century,!however.!In!1938,!60%!of!women!reported!agriculture!as!their! primary! activity.! By! 1980,! the! majority! of! women! identified! marketing! as! their! primary!occupation.416!However,!care!should!be!taken!interpreting!this!statement!as!respondents!may!not!have!perceived!household`related!tasks!as!a!“primary!activity”!category.!Devin!and!Erickson!have!noted!that!most!women! in! their! survey!were! away! from! the! house! for! an! average! of! 4.6! days! per!week,!which!meant! that! substitute! child! caregivers! were! required! during! these! periods.! The! survey! reported! that!men!were!perceived!as!the!“caregiver!of! last!resort”!when!grandmothers!or!older!daughters!were!not!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2003/03/22/000094946_03030704005682/Rendered/PDF/multi0page.pdf!!







413!M.!J.!N’Zengou`Tayo,!“Fanm!se!potomitan:!Haitian!woman!is!the!pillar!of!society,”!Feminist&Review!59!(1998),!pp.!118`142.!!

414!T.!T.!Schwartz,!Fewer&men,&more&babies:&Sex,&family&and&fertility&in&Haiti!(Lanham:!Lexington!Books,!2009).!415!Cultural!Consultation!Service,!Mental&health&in&Haiti:&A&literature&review!(February!2010).!Available!at!http://www.state.nj.us/humanservices/dmhs/disaster/MH_in_Haiti%20_Literature_Review.pdf!!

416!M.!J.!N’Zengou`Tayo,!“Fanm!se!potomitan:!Haitian!woman!is!the!pillar!of!society,”!Feminist&Review!59!(1998),!pp.!118`142.!

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available.! Aware! that! child! outcomes! are!worse!when! the! father! is! the! primary! caregiver,! Devin! and!Erickson! concluded! that! children! in! households! without! mature! female! family! members! were! at! a!disadvantage.417!!The!1994`1995!EMMUS!II!survey!found!that!39%!of!households! in!Haiti!were!headed!by!women.418!By!2008,! the! World! Bank! estimated! that! this! proportion! had! increased! to! 43.7%,419! while! Justensen!estimated!that!53%!of!households!were!headed!by!women!in!2007,!because!the!husband!had!migrated,!died,! or! never! taken!part! in! household!decisions.420! A! 2007! estimate!by! Lunde! is! closer! to! the!World!Bank!estimate,!at!42%,!and! indicated!that! in!1/3!of! these!cases,! the!women! is! the!head!of!household!even!though!the!husband!is!living!at!home.421!The!2005`2006!EMMUS!IV!survey!stated!that!even!though!93%! of! women! believed! that!men! should! help! with! housework! when! the!woman!works! outside! the!home,!and!79%!believed!that!the!woman!had!the!right!to!express!her!opinion!if!she!disagreed!with!her!husband,! only! 49%! of! women! in! 2006! disagreed! with! the! statement! that! important! household! level!decisions!should!be!made!by!men.422!Female!empowerment,!especially!in!terms!of!control!over!what!is!socially!considered!as!the!“woman’s!realm,”!remains!a!cause!for!concern!in!Haiti,!especially!as!it!relates!to!decisions!that!affect!the!security,!welfare,!and!development!of!the!household’s!children.!!In! addition! to! witnessing! clearly! defined! gender! roles,! children! in! Haiti! also! grow! up! in! defined! age!hierarchies.! Elderly! parents! typically! rely! on! their! children! for! their! retirement,! and! are! highly!respected.423!As!the!Cultural!Consultation!Service!observed,!“if! three!or!more!generations!are! living! in!the! house,! power! and! authority! are! generally! assumed! in! the! following! order:! grandparents,! father,!mother,!the!eldest!child!and!so!on.!Most!Haitians!have!no!old!age!pensions,!savings!or!social!security.!Their!children!are!their!source!of!social!security.”424!!The! low!position!of! children! in! the! family! hierarchy! is!manifest! in! their! household! responsibilities.! As!noted!above,!children!generally!perform!time`consuming!tasks!that!allow!adults!to!spend!their!time!on!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!417!R.!B.!Devin!and!P.!I!Erickson,!“The!influence!of!male!care!givers!on!child!health!in!rural!Haiti,”!Social&Science&&&Medicine!43/4!(1996),!pp.!479`488.!


419!World!Bank,!Genderstats&database:&Latin&America&and&the&Caribbean.!Available!at!http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTGENDER/EXTANATOOLS/EXTSTATINDDATA/EXTGENDERSTATS/0,,contentMDK:21442622~menuPK:4851685~pagePK:64168445~piPK:64168309~theSitePK:3237336,00.html!


421!H.!Lunde,!Haiti&youth&survey&2009&5&Volume&I:&Tabulation&report,!Fafo!report!2009/53!(2009).!Available!at!http://www.fafo.no/pub/rapp/20143/20143.pdf!!




!


income`generating!activities.425! Smucker!and!Murray! state! that!parents’!expectations!of! their! children!change!at!around!age!six,!after!which!point!the!children!are!expected!to!serve!in!the!household!as!adults!and!engage! in! income`generating!activities,!predominantly!agriculture!and!marketing.426,427!Children! in!slum! areas,! especially,! are! introduced! to! street! trading! and! menial! work! that! does! not! require!supervision.428!Child!labor,!whether!performed!within!or!outside!the!house,!bears!the!risk!of!exploitation!and! interfering! with! the! child’s! education! and! development,! violating! the! rights! of! the! child.! These!topics! are! reviewed! in! Chapter! 9.& Labor& and& economic& participation.! Family! expectations,! economic!necessity,! and! children’s! traditionally! low! status! within! the! family! may! therefore! contribute! to! their!exploitation!and!ongoing!risks!to!their!protection!and!development.!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!425!T.!T.!Schwartz,!Fewer&men,&more&babies:&Sex,&family&and&fertility&in&Haiti!(Lanham:!Lexington!Books,!2009).!426!G.!R.!Smucker!and!G.!F.!Murray,!The&uses&of&children:&A&study&of&trafficking&in&Haitian&children,!USAID/Haiti!Mission!(December!2004).!Available!at!http://pdf.usaid.gov/pdf_docs/PNADF061.pdf!!

427!S.!C.!Wortham,!“The!young!child!and!social!relationships!in!developing!countries,”!in:!M.!R.!Jalongo!(ed),!Enduring&bonds:&the&significance&of&interpersonal&relationships&in&young&children’s&lives!(Indiana:!Springer,!2007).!


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4.&Migration&and&movement&


4.&Migration&and&movement&!Since!the!1960’s,!Haiti!has!experienced!net!international!emigration,!with!more!individuals!exiting!than!entering! the!country! (Figure!44).429! In!2005,!approximately!170,000!Haitians!emigrated,!while! roughly!30,000! individuals! immigrated,! resulting! in! the! “net!migration”!of!140,000!people.430,431! In! the!period!2000`2005,!the!country!saw!an!emigration!rate!of!2.3!per!1,000!people,!or!0.23%.432!This!rate!was!lower!than!those!observed!during!the!periods!1985`1990!(2.8!per!1,000),!1990`1995!(3.4!per!1,000),!and!1995`2000!(2.6!per!1,000).433,434!However,!the!2000`2005!rate!still!suggested!the!continuing!desire!of!many!Haitians! to! leave! their! own! country! in! search! of! a! better! life! elsewhere,! despite! the! significant! cost!associated!with!migration.!Net!migration!from!Haiti!increased!sharply!in!2010,!when!it!was!estimated!that! approximately! 240,000! people! left! the! country.435! This! increase! reflects! the! impact! of! the!earthquake,!as!many!left!Haiti!in!the!wake!of!the!disaster.!To!this!day,!it!is!uncertain!what!proportion!of!these!international!migrants!were!children.!!!


430!UNDP,!Human&development&report&2009:&Overcoming&barriers:&Human&mobility&and&development!(New!York:!Palgrave!Macmillan,!2009).!Available!at!http://hdr.undp.org/en/reports/!!






!


Figure.44:.Net.number.of.immigrants,.1960T2010.

Data!source:!World!Bank,!World&development&indicator&database.!Available!at!http://databank.worldbank.org/ddp/home.do?Step=12&id=4&CNO=2!

!!Of! the! estimated! 170,000! Haitians! who! emigrated! in! 2005,! 13,542! were! classified! refugees,! though!again,! it! is! unclear!what! proportion! of! these! refugees!were! children.436! By! 2008,! the! total! number! of!refugees!fleeing!Haiti!had!increased!to!approximately!23,000.!This!increase!was!potentially!the!result!of!both!civil!unrest!and!post`hurricane!season!flight,!as!the!2008!season!caused!a!particularly!large!degree!of! damage! to! Haiti’s! infrastructure.437! In! 2010,! this! number! again! increased—this! time! to! 25,892—primarily!as!a!result!of!the!January!2010!earthquake.438!However,!despite!sharing!a!land!border!with!the!Dominican! Republic,! UNICEF! noted! that! there! was! not! a! particularly! high! rate! of! emigration! to! the!neighboring!country!during!this!period.439!!!The! International! Crisis! Group! estimated! that! in! 2007,! there! were! around! 3! million! Haitians! living!abroad.! These! émigrés! consisted! predominantly! of! wealthy,! middle! class,! and! educated! individuals,!some!of!whom!are! in! political! exile,! while! a! smaller! portion! of! the!more! recent! émigrés! consisted!primarily! of! members! of! Haiti’s! working! class.440! In! contrast,! the! Haitian!Ministry! for! Haitians! Living!





440!Cited!in:!ALNAP,!Haiti&earthquake&response:&Context&analysis!(July!2010).!Available!at!http://www.alnap.org/pool/files/haiti`context`analysis`final.pdf!

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Abroad! estimated! that! there!were! only! approximately! 1.5!million!Haitians! living! in! other! countries! in!2007.441!!According! to! the! UNDP,! an! estimated! 64.3%! of! Haitian! migrants! in! 2000`2003! relocated! to! North!America.442!Estimates!of!the!number!of!Haitians!in!North!America!vary!by!source,!ranging!from!500,000!(Caribbean!Country!Management!Unit)! to!2!million! (World!Bank).443,444,445,446!The!proportion!of! these!individuals! residing! in! the! United! States,! specifically,! is! unclear,! with! estimates! varying! from! 500,000!(Cultural! Consultation! Service)! to! 2! million! (World! Bank).447,448! It! is! estimated! that! approximately!100,000!Haitian!emigrants!reside!in!Canada.449,450!!In!addition!to!those!in!North!America,!between!500,000!and!550,000!Haitians!and!Dominicans!of!Haitian!descent!are!believed!to! live! in!the!Dominican!Republic.!These!migrants!mostly!work!on!plantations,! in!the!construction!industry,!and!as!domestic!servants.451,452,453!Up!to110,000!Haitians!are!also!believed!to!have!migrated!to!the!Bahamas!and!neighboring!French!islands!prior!to!the!2010!earthquake.454,455!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!441!PAHO,!Health&in&the&Americas&2007:&Volume&II&–&countries:&Haiti!(2007).!Available!at!http://www.paho.org/hia/archivosvol2/paisesing/Haiti%20English.pdf!


443!Cultural!Consultation!Service,!Mental&health&in&Haiti:&A&literature&review!(February!2010).!Available!at!http://www.state.nj.us/humanservices/dmhs/disaster/MH_in_Haiti%20_Literature_Review.pdf!

444!PAHO,!Health&in&the&Americas&2007:&Volume&II&–&countries:&Haiti!(2007).!Available!at!http://www.paho.org/hia/archivosvol2/paisesing/Haiti%20English.pdf!



446!World!Bank,!Social&resilience&and&state&fragility&in&Haiti:&A&country&social&analysis,!Caribbean!Country!Management!Unit,!Report!no.!36069`HT!(April!2006).!Available!at!http://siteresources.worldbank.org/SOCIALANALYSIS/1104894`1115795935771/20938696/Haiti_CSA.pdf!










!


!The!World! Bank! noted! that! 30%!of! all! Haitian! households! and! 44%!of!metropolitan! households! have!“close! relatives”! living! abroad.! Of! those! living! abroad,! 72%! were! reported! to! live! in! highìncome!countries,!such!as!the!United!States!and!Canada.456!While!high!levels!of!migration!among!the!educated!elite!present!Haiti!with!a!potential!“brain!drain”!effect,!the!Haitian!diaspora!does!play!a!significant!part!in! supporting! the!economic! livelihoods!of! those! relatives! remaining! in!Haiti:! émigrés! send! “home”!an!estimated!$800!million!every!year.457,458!!!Migration!within!Haiti!occurs!predominantly!from!rural!to!urban!areas.459!In!2001,!it!was!estimated!that!20.4%!of!Haitians!had!migrated! from!their!Department!of!birth! to!another!Department! (Figure!45).460!The! Portàu`Prince! metropolitan! area,! where! 51%! of! current! residents! were! born! elsewhere,! is! the!primary! destination! for!most! internal!migrants.461! As! a! result,! the!Ouest! Department,! containing! the!Portàu`Prince! metropolitan! area,! had! the! highest! proportion! of! residents! who! had! been! born! in! a!different! Department—approximately! 36.7%! had! been! born! elsewhere.! Despite! poor! job! prospects,!Portàu`Prince!draws!approximately!100,000!individuals!from!rural!areas!every!year,462!and!the!search!for! economic!opportunity! remains! the!primary!motivation! for! internal!migration.463! The!World!Bank!reports! that! “nearly! 17%! of! all! Haitians! over! the! age! of! 18! have!migrated! at! some! point! to! Portàu`Prince.”464!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!455!World!Bank,!Social&resilience&and&state&fragility&in&Haiti:&A&country&social&analysis,!Caribbean!Country!Management!Unit,!Report!no.!36069`HT!(April!2006).!Available!at!http://siteresources.worldbank.org/SOCIALANALYSIS/1104894`1115795935771/20938696/Haiti_CSA.pdf!











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!Participation! in! internal! migration! has! been! linked! to! significantly! reduced! chances! of! living! in!poverty.465,466! A! 2006! World! Bank! report! found! that! those! who! migrated! from! one! Department! to!another! demonstrated! a! 24%! reduction! in! the! probability! of! living! on! less! than! $2! per! day! when!compared! to! peers! who! had! never! migrated,! at! 30%! and! 54%,! respectively.! However,! this! report!revealed! little!difference!between!those!who!migrated!from!one!rural!area!to!another!and!those!who!never!migrated!from!their!original!rural!home.!Individuals!who!migrated!to!Port`au`Prince!exhibited!an!8%! lower!probability!of! living!below!$1!per!day! than!those!who!had!not!migrated,!with!no!difference!between!those!migrating!from!rural!and!other!urban!areas.467!Justesen!and!Verner!have!proposed!that!these! effects! may! be! primarily! due! to! the! higher! average! educational! attainment! of! those! who!migrate.468! Internal! migrants! possess! an! average! of! three! more! years! of! education! than! do! non`migrants.469!!Figure.45:.Prevalence.of.lifetime.migration,.by.Department,.2001.

!Source:!World!Bank,!Social&resilience&and&state&fragility&in&Haiti:&A&country&social&analysis,!Caribbean!Country!Management!Unit,!Report!no.!36069`HT!(April!2006).!Available!at!http://siteresources.worldbank.org/SOCIALANALYSIS/1104894`1115795935771/20938696/Haiti_CSA.pdf!!

!!The!January!2010!earthquake!had!an!immediate!impact!on!internal!migration.!According!to!Bengtsson!et&al.,!who!used!cell!phone!movement!to!determine!internal!migration!from!earthquake`affected!areas,!







!


approximately! 570,000! people! (22%)! left! Portàu`Prince! between! January! 12! and! 31.! The!majority! of!those!displaced!from!Portàu`Prince!moved!to!the!Sud,!Ouest,!and!Artibonite!Departments!(outside!of!the! Portàu`Prince! metropolitan! area),! causing! significant! increases! in! these! Departments’!populations.! Sud! and! Nippes! Departments! witnessed! the! largest! increase! from! preèarthquake!population! levels,! at! 19%! and! 18%! respectively,! followed! by! Grande‘Anse! and! SudÈst! Departments,!which!witnessed!increases!of!10%!each.470!!Despite! a! period! of! intense! migration! from! Portàu`Prince! in! the! two! weeks! following! the! 2010!earthquake,! migration! to! the! capital! was! soon! reestablished! and! once!more! surpassed!migration! to!other! Departments.! Bengtsson! et& al.! estimated! that! 68%! of! those! who! entered! the! Portàu`Prince!metropolitan!area!between!February!1!and!March!11!were!residents!prior!to!the!earthquake.471!While!reasons! for! a! net! return! to! the! capital! can! be! hypothesized,! no! research! has! been! conducted! to!determine!individual!motivations.!By!March!11,!the!Portàu`Prince!population!was!estimated!to!be!15%!smaller! than!before! the!earthquake,! indicating! that!not!all! former! residents!were!willing!or!able! to!return! to! the! capital.472! Two! years! later,! it! remains! unclear!what! percentage! of! Portàu`Prince’s! preèarthquake!residents!have!returned.!!By! March! 2010,! an! estimated! 1.1! million! Haitian! people! had! been! displaced! by! the! earthquake,!according! to! the! International! Organization! for! Migration! (IOM).! Of! this! 1.1! million,! 692,000! were!believed! to! be! living! in! 591! identified! IDP! camps!within! Portàu`Prince,!while! the! others! had! left! the!capital.!During!the!same!period,!the!Haitian!Government!estimated!that!511,495!people!had!migrated!from!Portàu`Prince.473!In!June!2010,!the!Camp!Coordination!and!Camp!Management!Cluster!reported!that!1.6!million!people!had!been!displaced!across!1,272!sites!Haiti`wide.474!These!larger!figures!may!be!the!result!of!a!more!comprehensive!assessment.!As!of!September!2011,!the!IOM!estimated!that!there!were! 550,000! Haitians,! or! 135,961! households,! living! in! 802! camps! in! earthquakeàffected! areas—a!reduction!of!64%!since!July!2010.475!!Of! significant! concern! to! child! protection! are! recent! efforts! to! close! camps,! often! forcibly,! on! both!private!and!public! land.!Upon!assuming!office,!President!Martelly! resolved! to!close! six! large!camps! in!the! metropolitan! area.! With! support! from! the! World! Bank,! those! living! in! the! camps! were! to! be!relocated! to! 16! redeveloped! neighborhoods.! Relocated! families! were! to! receive! US$125! in!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!470!L.!Bengtsson,!X.!Lu,!R.!Garfield,!et!al.,!Internal&population&displacement&in&Haiti:&Preliminary&analyses&of&

movement&patterns&of&Digicel&mobile&phones!(May!2010).!471!L.!Bengtsson,!X.!Lu,!R.!Garfield,!et!al.,!Internal&population&displacement&in&Haiti:&Preliminary&analyses&of&

movement&patterns&of&Digicel&mobile&phones!(May!2010).!472!L.!Bengtsson,!X.!Lu,!R.!Garfield,!et!al.,!Internal&population&displacement&in&Haiti:&Preliminary&analyses&of&

movement&patterns&of&Digicel&mobile&phones!(May!2010).!473!World!Vision,!Rapid&assessment&report:&Haiti&earthquake&response!(March!2010).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/Full_Report_583.pdf!!

474!IOM,!Displacement&tracking&matrix:&Summary&of&IDP&situation,!Haiti!CCCM!Cluster!(June!2010).!475!IOM,!Displacement&tracking&matrix:&V2.0&update,!Haiti!CCCM!Cluster!(September!2011).!Available!at!http://www.cccmhaiti.info/pdf/DTM_V2_Report_September_English.pdf!!

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assistance.476! This! initiative! indicates! a! desire! on! the! part! of! the! Haitian! government! and! response!community! to! provide! for! the! needs! of! those! still! displaced! by! the! earthquake,! as! 94%! of! camp!inhabitants! said! that! they! would! like! to! relocate! if! alternate! housing! was! available.! However,!most!camp!inhabitants!also!said!that!they!would!not!be!able!to!pay!rent!or!other!expenses!if!they!had! to! relocate! immediately.!This! finding! calls! into!question!both! the! feasibility! and!equity!of! the!relocation!strategy.477!!According! to! Haiti’s! Institute! for! Justice! and! Democracy,! many! camps! within! the! Port`au`Prince!metropolitan! area! have! been! forcibly! cleared,! most! notably! the! Sylvio! Cator! stadium.! Reportedly,!municipal! officials! and! the!Haitian! national! police! used! the! threat! and! implementation! of! violence! to!clear!the!stadium.!Additionally,!the!Institute!highlighted!that!the!US$125!relocation!payment!to!families!was!not!enough!to!secure!adequate!housing,!and!that!these!payments!appeared!to!be!allocated!based!upon!lists!of!households!in!camps!scheduled!to!close.!Unfortunately,!large!numbers!of!households!were!excluded!from!camp! lists,! leaving!many!families!without!compensation!or!a!means!of!reestablishment!following!camp!closures.478!!!

A.&Child&migration&!Prior!to!the!January!2010!earthquake,!child!migration!within!Haiti!was!generally!a!result!of!the!search!for!economic!opportunities,!both! for! the!children!themselves,!and! for! their!adult!caregivers.!As!noted!earlier,!scant! information!is!available!about!the!proportion!of! international!migrants!who!are!children,!save!estimates!of! the!number!of! children!migrating! to! the!Dominican!Republic,! specifically! (discussed!further! in!Section!9B.&Child& labor&migration&to&the&Dominican&Republic).!In!2007,!UNICEF!stated!that!between!2,000!and!3,000!children!were!estimated!to!have!crossed!to!the!Dominican!Republic!to!work!in!agriculture,!construction,!and!domestic!service!each!year.!Most!of!these!children!eventually!returned!to!Haiti!to!support!their!family!with!their!earnings.479!!!Several!factors!have!commonly!been!thought!to!contribute!to!youth!migration!in!Haiti.!One!such!factor!is! economic! security,! which! rural! youth! generally! seek! through! agriculture.! However,! inheritance!practices!and!environmental!degradation!create!a!situation!in!which!each!subsequent!generation!must!cultivate!smaller!plots!of!land!and!make!do!with!lower!agricultural!output!per!acre.!The!lower!prices!of!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!476!T.!Daniel,!"Haiti!mayor!says!he!plans!to!clear!huge!quake!camp,"!New&York&Times!(July!10,!2011).!Available!at!http://ijdh.org/archives/20587!

477!T.!Daniel,!"Haiti!mayor!says!he!plans!to!clear!huge!quake!camp,"!New&York&Times!(July!10,!2011).!Available!at!http://ijdh.org/archives/20587!

478!Institute!for!Justice!and!Democracy!in!Haiti,!Sylvio&Cator&stadium&and&Camp&Django&–&the&Government&of&Haiti’s&

continuing&campaign&to&close&IDP&camps&without&respecting&the&human&rights&of&displaced&communities!(August!9,!2011).!Available!at!http://ijdh.org/archives/20551!!


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subsidized!competing!imports!then!result!in!scanty!returns!for!those!relying!on!agriculture.!The!problem!is!even!greater!for!rural!youth!who!lack!land!rights!due!to!low!ownership`rent!rates!and!diminishing!plot!sizes!(see!Section!3F.&Family&structure).!As!a!result,!many!rural!youth!are!forced!to!search!for!livelihoods!and!education!in!urban!areas.480!!In!contrast,!a!2006!report!released!by!the!World!Bank,!using!2001!survey!data,!estimated!that!at!least!61.2%!of!internal!migration!undertaken!by!youth!and!adults!was!undertaken!for!reasons!other!than!the!migrant’s!search!for!economic!opportunity!(when!considering!each!migrant!individually,!rather!than!as!part!of!a!household!unit)! (Figure!46).481!Approximately!36.5%!of! those!who!reported!a!past!migration!stated! that! their! primary! motivation! was! to! follow! family! members,! while! 13%! cited! educational!reasons.482! Although! the! search! for! economic! security! may! have! been! indirectly! associated! with! the!choice!to!follow!a!migrating!family!member,!it!did!not!constitute!the!primary!motivation!to!migrate.483!When!considering!children,!the!proportion!of!those!who!migrate! in!order!to!follow!family!members! is!likely! to!be!greater! than! for!older!youth!and!adults,!and! it! is! reasonable!to!conclude!that!children!are!even!less!likely!than!older!individuals!to!migrate!for!reasons!having!to!do!with!economic!security.!!Figure.46:.Reason.for.migrating.(%):.Youth.and.adults,.2001.


!!Succeeding!as!a!young!migrant!in!urban!areas,!especially!in!Port`au`Prince,!requires!having!a!high!level!of!education,!as!well!as!an!established!network!of!contacts!who!can!assist!upon!arrival.!Lunde!notes!that!“for!uneducated!youth!without!existing!networks,!the!relocation!costs!related!to!migration!to!the!capital!become!so!high,!and!the!chances!of!succeeding!so!slim,!that!rural!youth!choose!rather!to!engage!in!high!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!480!H.!Lunde,!Young&Haitian&labour&migrants:&Risks&and&opportunities&in&Haiti&and&the&Dominican&Republic,!Fafo!Report!2010:!24!(2010).!Available!at!http://www.fafo.no/pub/rapp/20168/20168.pdf!!




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risk!illegal!migration!to!the!Dominican!Republic.”484!Despite!these!challenges,!the!World!Bank!concluded!that!youth!who!migrate!are,!ceteris&paribus,!more!successful!in!acquiring!gainful!employment!than!those!who!do!not!migrate.485!!The!January!2010!earthquake!may!be!viewed!as!having!both!a!catalyzing!and!an!inhibitive!effect!on!child!migration,! though! quantitative! indicators! are! few.! On! one! hand,! the! destruction! caused! by! the!earthquake! severely! affected! economic! capacity! in! the! Portàu`Prince! metropolitan! and! surrounding!urban!areas,!thus!decreasing!the!relative!attractiveness!(the!“pull”!factors)!of!migration!from!rural!areas!to!those!urban!centers.!It!also!restricted!the!overall!movement!of!children!in!search!of!work!and!made!adult!accompaniment!difficult.!Conversely,!youth!and!children!living!in!earthquakeàffected!areas!were!forced! to!migrate!as!a! result!of! the!destruction!of! their! former! residences!and! livelihoods.!Thus,! they!were!compelled!to!move!to!IDP!camps!and!unaffected!areas!for!the!same!reasons!given!by!those!who!had! traditionally!moved! to! the!Portàu`Prince!area—economic!and!educational!opportunities,!and! the!accompaniment!of!family.!UNICEF!estimated!that!330,000!of!the!661,000!people!still!displaced!outside!of!Portàu`Prince! six!months!after! the!earthquake!were!children,! though!more! recent!estimates!were!unavailable!at!the!time!of!this!writing.486!In!addition,!World!Vision!stated!that!most!children!who!were!displaced!after!the!earthquake!were!then!widely!dispersed!among!families!and!others!across!Haiti.487!!The!impact!of!the!earthquake!on!the!movement!and!migration!of!children!may!be!greater!than!that!for!other!segments!of! the!population.!The!earthquake!not!only!compelled!young!people!who!would!have!traditionally! migrated! to! the! capital! in! search! of! work! to! remain! in! agricultural! areas! and! displaced!others! from! damaged! urban! areas,! but! it! may! also! have! influenced! children’s! perceptions! of!vulnerability! and! risks! informing! their! decisions! of! whether! or! not! to! migrate,! due! to! the! death! of!parents!and!caregivers!(a!topic!discussed!further!in!Section!5D.&Children&without&parental&care).!!!

B.&Child&trafficking&!Before!an!analysis!of!child!trafficking!in!Haiti!is!possible,!it!is!necessary!to!define!the!term!“trafficking.”!The!most! comprehensive!definition! is! presented!by! the!UN!Protocol! to!Prevent,! Suppress! and!Punish!





!


Trafficking!in!Persons,!Especially!Women!and!Children,!adopted!in!December!2000!and!to!which!Haiti!is!a!signatory!but!has!not!yet!ratified.488!The!Protocol!defines!trafficking!as:!!

…! the! recruitment,! transportation,! transfer,!harbouring!or! receipt!of!persons,!by!means!of! the!threat! or! use! of! force! or! other! forms!of! coercion,! of! abduction,! of! fraud,! of! deception,! of! the!abuse! of! power! or! of! position! of! vulnerability! or! of! the! giving! or! receiving! of! payments! or!benefits!to!achieve!the!consent!of!a!person!having!control!over!another!person,!for!the!purpose!of!exploitation.489!

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Furthermore,!the!Protocol!specifies!that:!!

...! recruitment,! transportation,! transfer,! harbouring! or! receipt! of! a! child! for! the! purpose! of!exploitation!shall!be!considered! ‘trafficking! in!persons’!even! if! this!does!not! involve!any!of! the!means!set!forth!in!the!definition.490!

!Accordingly,!UNICEF!and!the!International!Labour!Organization!note!that!the!use!of!violence!or!fraud!is!not!necessary!for!the!practice!to!be!considered!trafficking!in!the!case!of!children.491!!The! Convention! on! the!Rights! of! the! Child! contains! a! number! of! Articles! that! are! typically! applied! to!determine!whether!a!situation!is!exploitative,!including:!Article!32!regarding!economic!exploitation!and!work! that! would! be! harmful! to! the! child’s! health,! safety,! and! development;! Article! 34! on! sexual!exploitation! and! abuse;! and! Article! 35! on! the! protection! of! children! from! treatment! as! chattel.!Additionally,! the! ILO! considers! child! trafficking! a! practice! similar! to! slavery! and! places! it! in! the! same!category!as!child!labor.492!!In!2002,!a!study!by!UNICEF!and!the!International!Organization!for!Migration!estimated!that!more!than!2,000! Haitian! children! are! trafficked! to! and! through! the! Dominican! Republic! every! year,493,494,495,496!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!488!UN!ODC,!Signatories&to&the&CTOC&trafficking&protocol!(2011).!Available!at!http://www.unodc.org/unodc/en/treaties/CTOC/countrylist`traffickingprotocol.html!!





493!UN!ESC,!Situation!of!human!rights!in!Haiti,!UN!Doc.!E/CN.4/2006/115!(2006).!Available!at!http://ap.ohchr.org/documents/dpage_e.aspx?m=47!!

494!UN!OCHA!Haiti,!Haiti&before&January&12th,!Internal!document!(2010).!Available!at!http://ochaonline.un.org/OchaLinkClick.aspx?link=ocha&docId=1165439!!



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with!an!additional!176,000!to!300,000!trafficked!domestically!within!Haiti.497!Due!to!its!proximity!and!relatively! porous! border! with! Haiti,! the! Dominican! Republic! is! the! largest! destination! country! for!trafficked!Haitian!children.!However,!trafficked!children!also!appear!in!the!Bahamas,!the!United!States,!Canada,!Europe,!and!Jamaica.498!While!there!are!no!publically!available!estimates,!the!U.S.!Department!of!State!asserted!that!NGOs!observed!an!increase!in!the!trafficking!of!Haitian!children!to!the!Dominican!Republic! and! the! Bahamas! in! 2008.499!Whether! or! not! this! increase! indicates! a! sustained! trend! over!time,!it!highlights!the!continuing!nature!of!the!phenomenon!and!the!need!for!further!action.!The!ILO!has!noted! that! the! trafficking! of! children,! especially! for! labor! and! sexual! exploitation,! is! a! hidden!phenomenon!that!complicates!rigorous!data!collection,!and!opined!that!statistics!should!be!considered!illustrative!of!such!underlying!issues,!rather!than!as!perfect!indicators.500!!The!type!of!work!in!which!trafficked!children!generally!must!engage!poses!disproportionate!risks!to!their!health,! safety,! and! future!opportunities.! Trafficked! children! are!often!employed! in! street! professions,!such!as!begging,!shoe!shining,!and!petty!sales,!or!in!hazardous!work!including!prostitution!(particularly!for! girls),! farming,! and! construction.501,502! They! are! deprived! of! education! and! a! supportive! family!environment,! and! are! often! forced! to! work! in! unsafe! environments! for! little! or! no! pay.! Young! girls!forced! into! prostitution! face! the! additional! risks! of! sexually! transmitted! diseases,! unwanted!pregnancies,!and!physical!violence!and!abuse.503,504!!!Comprehensive!strategies!to!alleviate!child!trafficking!impact!both!the!demand!and!supply!sides!of!the!phenomenon,! and! require! international,! regional,! and! national! cooperation.505! Prior! to! the! 2010!earthquake,!Haiti’s!strategy!for!suppressing!child!trafficking!centered!on!containment!at!airports!and!the!Dominican! border.! During! that! time,! MINUSTAH! representatives! were! stationed! with! immigration!officials!to!help!identify!children!being!trafficked!across!the!border!or!through!the!airport—a!“first!and!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!497!U.S.!Department!of!Labor,!Findings&on&the&worst&forms&of&child&labor:&2006&report:&Haiti!(2006).!Available!at!http://www.dol.gov/ilab/map/countries/haiti.htm!




501!OMCT,!Rights&of&the&child&in&Haiti!(October!2002).!Available!at!http://www.omct.org/files/2001/11/1155/haitichildren2002.pdf!





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last!line!of!defense”!strategy!that,!alone,!was!insufficient!to!prevent!the!illicit!movement!of!children.506!If! trafficked! children! were! instead! intercepted! in! another! country,! the! National! Office! of! Migration!attended!to!their!supervision!and!reintegration!upon!repatriation.507!!Haiti’s! January! 2010!earthquake! significantly! compounded! children’s! risk! of! trafficking.! In! the!months!following! the!earthquake,! reports!of! child! trafficking!and! illegal! adoption!dominated! the! international!press.508!UN!OCHA’s!Initial!Rapid!Assessment!revealed!that!7%!of!camps!in!Portàu`Prince,!9%!of!camps!outside! of! Portàu`Prince,! and! 13%! of! non`camp! sites! outside! of! the! capital! reported! at! least! one!instance!of!suspected!child!trafficking.509!!Cognizant!of! the! increased!risk!of!child! trafficking! in! the!relief!and!recovery!phase!of!postèarthquake!operations,! the! Haitian! Government! stated! that! the! establishment! of! “measures! for! combating!trafficking!and!dealing! in!Haitian!children”!was!a!priority! in! the!Post`Disaster!Needs!Assessment.510! In!association!with! UNICEF! and!MINUSTAH,! over! 100! staff! from! the! Brigade! de! Protection! des!Mineurs!(BPM)!of!the!Haitian!National!Police,!the!Institut!du!Bien!Être!Social!et!de!Recherches!(IBESR),!and!the!Ministère!des!Affaires!Sociales!et!du!Travail! (MAST)!were!trained! in! the!prevention!of!child! trafficking!and! other! forms! of! violence,! including! sessions! on! case!management! when! trafficking! situations! are!identified.!Between!January!and!July!2010,!6,000!cases!of!child!movement!across!the!Dominican!border!and!through!airports!had!been!assessed,!and!400!victims!had!been!assisted.511,512!In!March!2011,!UNICEF!stated!that!of!the!11,774!children!screened!at!the!Portàu`Prince!airport!and!other!border!checkpoints!in!all!of!2010,!459!were!identified!as!victims!of!child!trafficking.513!However,!it!is!not!clear!what!degree!of! impact! this! initiative! has! had! upon! the! overall! rate! of! child! trafficking,! since! the! postèarthquake!baseline!rate!and!number!of!successful!interventions!are!unknown.514,515!The!relatively!small!increase!in!the!number!of!identified!child!trafficking!victims!may!be!the!result!of!a!true!reduction!in!the!number!of!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!506!U.S.!Department!of!State,!Trafficking&in&persons&report&2009,!Office!to!Monitor!and!Combat!Trafficking!in!Persons!(June!2009).!Available!at!http://www.state.gov/documents/organization/123357.pdf!!

507!UN!Committee!on!the!Rights!of!the!Child,!Consideration!of!reports!submitted!by!state!parties!under!article!44!of!the!Convention:!Haiti,!UN!Doc.!CRC/C/51/Add.7!(2002).!Available!at!http://www.unhcr.org/refworld/docid/3df59ad34.html!


509!CDC,!CDC&summary&of&initial&rapid&assessment&conducted&by&UN&OCHA&in&Haiti!(February!2010).!510!Government!of!Haiti,!Haiti&earthquake&PDNA:&Assessment&of&damage,&losses,&general&and&sectoral&needs!(March!2010).!Available!at!http://siteresources.worldbank.org/INTLAC/Resources/PDNA_Haiti`2010_Working_Document_EN.pdf!



513!UNICEF,!OHCHR&Universal&Periodic&Review&–&Haiti!(March!2011).!Available!at!http://lib.ohchr.org/HRBodies/UPR/Documents/session12/HT/UNICEFèng.pdf!



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child! trafficking! attempts,! traffickers’! use! of! other! routes,! or! lower! rates! of! successful! identification,!though!the!impact!of!each!of!these!factors!remains!unknown.!!With!US$1.6!million!provided!by! the!U.S.!Government!and!UNICEF,! the! International!Organization! for!Migration!initiated!a!program!to!assist!1,000!victims!of!domestic!child!trafficking.!From!January!to!June!2011,!IOM!reported!that!they!had!assisted!400!domestic!trafficking!victims!who!had!been!living!in!IDP!camps,!with!additional!cases!identified!in!other!areas!of!Port`au`Prince!and!surrounding!provinces.516!!!

C.&Adoption&!Haiti!has!a!history!of!both!domestic!and! international! child!adoption,!although! international!adoption!predominates.! Haiti’s! current! domestic! and! international! adoption! framework! was! created! by! the!decree!of!April!4,!1974.! In!general,!domestic!adoption!predominates! for! the!10`15!year!age!group,!while! international! adoption! predominates!within! the! 1`3! year! age! group.!Adoption! is! authorized!when!it!is!perceived!that!“real!and!definite!advantages”!are!available!to!the!child!through!adoption.517!The! decree! of! 1974! outlines! age! requirements! for! those! seeking! to! adopt! a! Haitian! child,! both!domestically!and! internationally,!whereby!the!age!difference!between!the!child!and!the!adopter!must!be!at!least!19!years,!and!the!adopter!must!be!at!least!35!years!of!age.!However,!in!eligible!cases,!these!stipulations!may!be!waived!by!Haiti’s!President.!!!In! the!period!1994`1999,! the! Institut!du!Bien!Être! Social! et!de!Recherches! (IBESR)!documented!2,097!cases!of!international!adoption,!compared!to!only!338!cases!of!domestic!adoption.!The!UN!Committee!on! the!Rights!of! the!Child! stated! that! this!number!of! international!adoptions! represented!an! increase!over!previous!periods,!suggesting!that!the!number!of!cases!for!the!decade!2000`2009!was! likely!to!be!even!higher,!although!they!provided!no!specific!estimates.518!!Prior!to!the!January!12,!2010!earthquake,!many!pending!cases!of!adoption!of!abandoned!children!had!become! stalled!due! to! the! requirement! that!an!appeal!by! IBESR! for! the!child’s!parents!or! former!caregivers!to!come!forward!be!fulfilled,!to!which!there!was!never!a!response.519!Haiti!is!not!a!party!to!the! Hague! Convention! on! the! Protection! of! Children! and! Co`Operation! in! Respect! of! Inter`Country!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!516!UN!OCHA,!Humanitarian&bulletin:&3&May&–&6&June&2011!(2011).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/Full_Report_1060.pdf!!




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Adoption,! which! seeks! to! protect! children! from! the! risk! of! improper! and! illegal! adoption,! nor! does!domestic!Haitian!legislation!provide!a!comparable!degree!of!protection.520,521!Children!in!Haiti!thus!face!heightened! risks! to! their! protection—a! situation! both! highlighted! and! exacerbated! by! the! 2010!earthquake.!!Following!the!2010!earthquake,!the!issue!of!international!adoption!of!Haitian!children!soon!dominated!the! international! media.! Several! factors! converged! to! override! the! few! safeguards! that! existed! with!respect! to! international! adoption! of! Haitian! children.! The! proximity! of! the! crisis! to! the!United! States!meant!that!many!crisis`specific!organizations!converged!on!Haiti,!without!training! in,!or!awareness!of,!Haitian! and! international! regulations! governing! inter`country! adoption.! The! influx! of! U.S.! Christian!organizations,! which! have! increasingly! embraced! orphan! care! as! a! tenant! of! faith,! both! directly!responded!and!placed!political!pressure!on!their!government!to!ease!restrictions!and!requirements!for!the!adoption!of!Haitian!children.!The!U.S.!government,!under! the!seldomùsed!“humanitarian!parole”!procedure,! relaxed! visa! restrictions! and! pre`screening! requirements! of! both! prospective! adoptive!parents!and!Haitian!children.! It!also!overlooked!preèxisting!documentation! requirements! intended!to!prevent! fraud! and! trafficking.! Under! the! strain! of! the! crisis,! the! Haitian! government,! which! had! lost!significant! human! and! physical! resources! during! the! earthquake,! was! unable! to! insist! upon! and!implement!domestic!procedures!for!the!protection!of!children,!including!the!appeal!for!family!members!to! come! forward! and! claim! children! placed! in! orphanages.522! The! result,! as! Ginger! Thompson! of! the!New!York!Times!put!it,!“evolved!into!a!baby!lift!unlike!anything!since!the!Vietnam!War.”523!!In! the!months! following!the!earthquake,!more!than!1,150!children!were! fostered!to!U.S.! families!who!had!applied!for!adoption!prior!to!the!earthquake.!Thompson!noted!that!this!was!a!figure!higher!than!the!total!number!of!children!adopted!by!American!families!during!the!previous!three!years.!Despite!calls!to!limit!international!adoptions!following!the!earthquake!from!UN!agencies,!NGOs,!and!other!groups,!many!Haitian! orphanages,! including! some! that! had! not! been! affected! by! the! earthquake,! were! “nearly!emptied.”! These! actions! were! driven! by! the! perceived! priority! of! the! international! community! and!governments!to!remove!children!from!harm’s!way.524!Child!protection!remains!a!concern!for!those!who!were! evacuated! from! Haiti,! as! well! as! for! those!who! remained! following! the! 2010! earthquake.! Haiti!currently! seeks! to! revise! and! implement! adoption! regulations,! and! the! status! of! postèarthquake!international! adoptions! requires! monitoring.! Though! the! U.S.! government! closed! the! “humanitarian!parole”!process,!the!practice!of!placing!children!in!orphanages!as!a!result!of!the!socioèconomic!position!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!520!Hague!Conference!on!Private!International!Law,!Status:&Convention&of&29&May&1993&on&protection&of&children&

and&co5operation&in&respect&of&intercountry&adoption!(2011).!Available!at!http://www.hcch.net/index_en.php?act=conventions.status&cid=69!!


522!G.!Thompson,!“After!Haiti!quake,!the!chaos!of!U.S.!adoptions,”!New&York&Times!(August!3,!2011).!Available!at!http://www.nytimes.com/2010/08/04/world/americas/04adoption.html?pagewanted=all!



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of!their!families,!rather!than!the!death!of!their!parents,!is!a!factor!that!must!be!considered!with!regard!to!inter`country!adoption!following!the!earthquake.!

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5.&Child&protection&!Since!the!January!2010!earthquake!in!Haiti,!children!have!faced!a!myriad!of!protection!challenges.!More!than!1.5!million!children!were!directly!affected!by!the!earthquake,!many!more!were!indirectly!affected,!and! 500,000! were! left! extremely! vulnerable,! prompting! UNICEF! to! label! the! disaster! a! “children’s!emergency.”525,526!Because!threats!arising!from!the!earthquake!compounded!preèxisting!deficiencies!in!child!protection!systems!and!structures,!and!further!marginalized!children!and!youth!in!Haitian!society,!fulfilling! children’s! rights! will! require! a! paradigm! shift! from! preèarthquake! “businessàsùsual”! to!“building!back!better.”!!Narrow!definitions!of!“child!protection”!have!hampered!the!comprehensive!assessment!required!for!an!adequate!response!to!Haiti’s!fragile!child!protection!situation.!In!2006,!UNICEF!stated!that!it!used!“child!protection”! to! refer! to! “preventing! and! responding! to! violence,! exploitation! and! abuse! against!children—including! commercial! sexual! exploitation,! trafficking,! child! labor! and! harmful! traditional!practices,! such! as! female! genital! mutilation/cutting! and! child!marriage.”527! However,! this! constricted!definition!conflates!categories!and!characteristics!of!risk!and!need,!and!undermines!the!assessment!of!need!itself.!While!arguably!useful!for!targeting!offenders,!this!definition!excludes!some!of!the!genuine!threats!faced!by!Haiti’s!children.!!!These!UNICEF! categories! and! characteristics! alone! are! not! optimal! tools! for! defining! child! protection!needs.! Instead,! a!more!holistic!definition!of! child!protection! that!encompasses!a!wider! range!of! child!protection!risk!factors!and!outcomes,!as!well!as!the!dynamic!processes!that!connect!them,!is!required.!Indeed,!UNICEF! notes! that! one! of! the! challenges! confronting! the! assessment! and! promotion! of! child!protection!is!the!lack!of!an!appropriate!and!uniform!definition!of!the!term.528!!In! contrast! to! limited!categorical!definitions!of! child!protection,! the! InterÀgency!Standing!Committee!proposed! the! following! definition! of! protection! under! their! 1999! framework! for! the! protection! of!internally!displaced!persons:!!

The!concept!of!protection!encompasses!all!activities!aimed!at!obtaining!full!respect!for!the!rights!of!the!individual!in!accordance!with!the!letter!and!the!spirit!of!the!relevant!bodies!(human!rights,!humanitarian!law,![and]!refugee!law).529!

!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!525!UNICEF,!Children&of&Haiti:&Milestones&and&looking&forward&at&six&months!(July!2010).!Available!at!http://www.unicef.org/emerg/files/UNICEF_Haiti_`_Six_Months_Report_Final.pdf!!




529!ICRC,!Report&of&the&third&workshop&on&protection&for&human&rights&and&humanitarian&organizations:&Doing&

something&about&it&and&doing&it&well,!18`20!January!1999!(January!2000).!

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5.&Child&protection&


Protection!as!a!set!of!activities!directed!towards!the!realization!of!human!rights!is!a!marked!departure!from!categorical!definitions!and!facilitates!a!broader!assessment!of!risk!factors,!systems,!and!outcomes!than! do! issue`specific! conceptualizations.!Moreover,! it! affirms! a! “positive”! approach! to! protection! by!suggesting!that!human!security!depends!not!only!the!absence!of!violence,!exploitation,!and!abuse,!but!also! on! the! existence! of! an! environment! that! reduces! vulnerability! and! promotes! access! to!opportunities.530! Child! protection! in! this! sense! is! a! multi`tiered! framework! in! which! the! child’s!experience!is!not!assessed!in!isolation,!but!rather!with!respect!to!families,!communities,!and!the!country!as!a!whole.531!!Because! the!development!of! indicators! requires! conceptual! clarity,! the! lack!of! unanimity! surrounding!the! definition! of! child! protection! has! led! to! significant! challenges! in! assessment,! monitoring,! and!evaluation.! UNICEF! notes! that! the! introduction! of! the! Demographic! and! Health! Surveys! (DHS),! the!Multiple! Indicator!Cluster!Surveys,!and! their!Haitian!corollaries,! the!EMMUS!surveys,!have! filled!some!critical! gaps! in!what! is! known!about! child!protection! in!Haiti.532!Nonetheless,!many!areas! continue! to!suffer!from!a!lack!of!rigorous!indicators!and!data,!either!because!appropriate!indicators!do!not!exist,!or!because! household! surveys! are! an! ineffective!method! to! quantify! certain! phenomena.! In! this! sense,!building! state! capacity! is! not! only! necessary! for! the! implementation! of! policies! and! programs! that!promote! child! protection,! but! also! for! the! collection! and! dissemination! of! data! for! planning,!implementation,!monitoring,!and!evaluation!purposes.533!!!

A.&Safety&and&security&!In! addition! to! observable! outcomes,! human!protection! is! inextricably! linked! to! individual!perceptions!about! self! and! community.! High! levels! of! social! cohesion! and! trust! in! the! community! reduce! young!people’s! feelings! of! insecurity,! contributing! to! environments! that! enable! and! foster! children’s! rights.!Strong! social! cohesion! also! facilitates! children’s! access! to! otherwise! unavailable! community`based!psychosocial!supports,!further!enhancing!coping!and!resilience.534,535!Prior!to!the!2010!earthquake,!58%!of!residents!in!Port`au`Prince!reported!feeling!unsafe!“often!or!most!of!the!time”!at!home,!compared!to!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!530!Sphere!Project,!Sphere&protection&section:&Draft!(June!23,!2011).!Available!at!http://www.crin.org/docs/FileManager/Sphere_Protection_Chapter_23Junedraft1.doc!!




534!U.!Bronfenbrenner,!The&Ecology&of&Human&Development:&Experiments&by&Nature&and&Design!(Cambridge,!MA:!Harvard!University!Press,!1979).!

535!T.!S.!Betancourt,!R.!T.!Brennan,!J.!Rubin`Smith,!et!al.,!“Sierra!Leone’s!former!child!soldiers:!A!longitudinal!study!of!risk,!protective!factors,!and!mental!health,”!Journal&of&the&American&Academy&of&Child&and&Adolescent&

Psychiatry!49/6!(2010),!pp.!606`615.!Available!at!http://www.hsph.harvard.edu/mch`cyf`concentration/files/betancourt_et_al._2010_jaacap.pdf!

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15%!of!those!in!rural!areas.536!In!2009,!only!18%!of!urban!young!people!aged!10`24!reported!feeling!that!most! people! could! be! trusted.! Trust! among! young! people! in! rural! areas! was! almost! double! this!percentage,! at! 35%.537! Though! remarkably! low,! these! proportions! are! a! notable! increase! over! the!proportion! of! young! people! who! believed! that! they! could! trust! others! in! their! community! at! the!conclusion!of!civil!unrest!only!two!years!earlier;!in!2007,!only!one!out!of!every!10!youth!felt!they!could!generally! trust!others! in! their!community.538,539!Discrepancies!between!urban!and!rural!areas!highlight!the! impact! of! social! cohesion! and! community! bonds! on! an! individual’s! sense! of! security.540! These!differences! stem! from! a!multitude! of! factors,! including! higher! crime! rates! in! cities,! political! violence!concentrated! in! urban! areas,! and! the! prominence! of! reciprocal! collective! labor! groups,! such! as! the!coumbite,!the!eskwad,!and!the!societé&de&travail,!in!rural!regions.541!!The! January! 2010! earthquake! devastated! the! sense! of! security! of! those! in! affected! areas.! A! Joint!Security! Assessment! by! MINUSTAH! and! intergovernmental,! governmental,! and! non`governmental!partners!in!March!2010!found!“a!near!unanimous!perception!of!insecurity!among!IDPs!in!camps.”542!One!month!later,!this!sense!of!insecurity!had!fallen,!with!45%!of!internally!displaced!persons!(IDPs)!reporting!that! they! felt! insecure.!Notably,!heightened! feelings!of! insecurity!were!not! limited! to! IDPs! in!Port`au`Prince,!with!more! than! 50%! of! IDPs! in! camps! in! Port`de`Paix! (Nord!Department)! and! Les! Cayes! (Sud!Department)!also!reporting!insecurity.543!!The! causes! of! heightened! insecurity! among! IDPs! can! be! categorized! as! human`,! system`,! and!environment`centric.!Human`centric! causes!are!directly! related! to! trust!and! social! cohesion.! In!March!2010,!MINUSTAH!reported!that! IDPs! linked!insecurity!to!heightened!risk!of!rape,!other!violence,!theft,!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!536!World!Bank,!Social&resilience&and&state&fragility&in&Haiti:&A&country&social&analysis,!Caribbean!Country!Management!Unit,!Report!no.!36069`HT!(April!2006).!Available!at!http://siteresources.worldbank.org/SOCIALANALYSIS/1104894`1115795935771/20938696/Haiti_CSA.pdf!

537!H.!Lunde,!Haiti&youth&survey&2009&5&Volume&I:&Tabulation&report,!Fafo!report!2009/53!(2009).!Available!at!http://www.fafo.no/pub/rapp/20143/20143.pdf!

538!M.!Justesen!and!D.!Verner,!Factors&impacting&youth&development&in&Haiti,!World!Bank!policy!research!working!paper!No.!4110!(2007).!Available!at!http://ddp`ext.worldbank.org/EdStats/HTIprwp07.pdf!






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and!the!presence!of!escaped!prisoners!and!gangs.544!The!University!of!Michigan!and!Small!Arms!Survey!of!April!2010!found!that!3.4%!of!respondents!in!the!Port`au`Prince!metropolitan!area!had!been!victims!of! property! crimes! since! the! earthquake.! Theft! of! water! and! food! were! the! most! common! crimes,!especially! in!the!neighborhoods!of!Delmas,!Martissant/Gran!Ravine,!Bel!Air,!Cite!Solei,!Petionville,!and!Carrefour.545! Respondents! to! MINUSTAH’s! Joint! Security! Assessment! also! reported! high! levels! of!insecurity! due! to! system`related! factors,! including! lack! of! support! networks! and! state! capacity,! high!unemployment! rates,! inadequate! food! distribution,! and! lack! of! access! to! healthcare,! education,! and!other!basic! services.546!Destruction!caused!by! the!earthquake!exacerbated! these!concerns!by!creating!continued!distress!about!physical!environments,! including!the!possibility!of!aftershocks,! the!upcoming!rainy! season,! the! vulnerability! of! shelters,! poor! living! conditions,! and! uncertainty! about! future!opportunities.547!Each!cause!of!insecurity!has!impacted!child!protection!in!Haiti,!due!to!both!the!threat!itself,! and! its! impact! on! families’! and! communities’! sense! of! insecurity.! The! creation! of! an! enabling!environment!for!child!protection!in!Haiti!must,!therefore,!seek!not!only!to!alleviate!threats!to!children’s!security,!reduce!vulnerability,!and!promote!the!resilience!of!IDPs!and!their!children,!but!also!to!address!the!enduring!sense!of!insecurity!caused!by!the!earthquake!and!its!aftermath.!!A!population!survey!by!World!Vision!from!February!4`6,!2010!found!that!respondents!in!Port`au`Prince!and! World! Vision! operational! areas! overwhelmingly! identified! children! as! the! most! vulnerable!population! sub`group! following! the! earthquake! (Figure! 47).548! According! to! this! survey,! children’s!vulnerabilities! stemmed! from!both!physical! and!mental! factors.! The!eight!most! common!components!identified!by!respondents!were:!1)!infections!and!sickness!with!no!available!treatment;!2)!lack!of!shelter;!3)!inability!to!take!care!of!themselves;!4)!lack!of!protection!and!security;!5)!inability!to!run!from!danger;!6)! fear! of! “evil! forces”;! 7)! separation! from! parents;! and! 8)! having! “lost! their! dreams.”549! These!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!544!UN!MINUSTAH,!IDP&camp&joint&security&assessment&report,!MINUSTAH!Human!Rights!Section!(March!2010).!Available!at!http://oneresponse.info/Disasters/Haiti/Protection/publicdocuments/Joint%20Security%20Assessment%20report%20`%20Final.doc!!

545!A.!R.!Kolbe,!R.!Muggah,!R.!A.!Hutson,!et!al.,!Assessing&needs&after&the&quake:&Preliminary&findings&from&a&

randomized&survey&of&Port5au5Prince&households,!University!of!Michigan/Small!Arms!Survey!(April!2010).!Available!at!http://www.comunidadesegura.org/files/Results%20of%20a%20Random%20Survey%20of%20Haitian%20Households.doc!!





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challenges! are! in! addition! to! those! confronting! the!population!as! a!whole,! including! lack!of! access! to!food,!clothing,!and!family!residences!in!exposed!camps.550!!!Figure.47:.Most.atTrisk.population.subgroups.after.2010.earthquake.according.to.household.heads.in.PortTauTPrince.and.World.Vision.operational.areas,.March.2010.


!!

B.&Violence&!Violence!against!children! is!a!multi`faceted!concept! including!physical!and!mental!abuse,!exploitation,!sexual!abuse,!and!negligent!treatment.!Violence!carries!the!risk!of!many!long`term!effects!and!can!occur!across!a!range!of!settings,! including!the!home,!the!street,!the!school,!and!the!workplace,!as!well!as! in!justice! institutions! and! alternative! care! facilities.551! Physical! and! psychological! violence!may! result! in!temporary!or!permanent!disability;!undermine!adult!development;!compromise!the!ability!to!socialize,!learn,!and!engage!with!the!community;!and!perpetuate!inter`generational!normalization!of!violence.!In!the!worst!cases!of!physical!and!mental!abuse,!death!may!result!from!either!physical!injury!or!suicide.552!In!2003,!for!example,!it!was!estimated!that!6%!of!all!deaths!among!Haitians!in!the!15`19!year!age!group!were!connected!with!assaults.553!!!The! 2001! Haitian! law! prohibiting! corporal! punishment! in! a! range! of! settings! defines! inhumane!treatment,!which!constitutes!corporal!punishment,!in!Article!2:!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!550!World!Vision,!Rapid&assessment&report:&Haiti&earthquake&response!(March!2010).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/Full_Report_583.pdf!!




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!Inhuman[e]!treatment!is!defined!by!any!action!that!causes!a!bodily!or!emotional!shock!to!a!child,!such!as!hitting!or!pushing,!or!inflicting!any!punishment!that!causes!damage!to!the!child,!using!or!without!the!intermediary!of!an!object,!weapon!or!abusive!physical!force.554!!

In!Haiti,! violence!against!children!does!not!only!occur! in! the!context!of!corporal!punishment.! Instead,!violence!is!a!regular!part!of!children’s!lives!and!is!normalized!to!some!degree!across!society.555!Though!some!forms!of!violence!against!children,!such!as!their!participation! in,!and!victimization!by,!gangs!and!other!armed!groups,!are!socially!condemned,!other!forms!in!more!“controlled”!environments!including!schools!and!the!home!are!accepted!as!a!regular!part!of!child`rearing.556!A!2004!study!found!that!60%!of!women!and!85.7%!of!men!reported!that!they!had!been!mistreated!at!a!moderate!or!severe!level!during!childhood.557!!Violence!against!children! in!Haitian!households!occupies!a! legal!grey`area.!While!Article!1!of!the!2001!law! prohibiting! corporal! punishment! states! that! “(t)he! inhuman! treatment! of! any& nature! comprising!corporal!punishment!of!a!child!is!forbidden”!(emphasis!added),!the!other!major!contextual!provisions!of!the!legislation!deal!exclusively!with!organizations,!schools!and!other!institutions,!without!specifying!the!home! as! an! environment! under! the! auspices! of! the! law.! Without! any! known! public! education! or!awareness`raising! campaigns! regarding! the! law,! NGOs! are! uncertain!whether! corporal! punishment! is!prohibited,!either!de&facto&or!de&jour.558!!Corporal! punishment! in! the! home,! including! spanking! and! beating,! is! widely! used! as! a! method! of!discipline.559!Harsh!treatment!of!children!is!driven!by!parents’!fear!that!failing!to!reprimand!a!child!will!lead! to!children! “getting!out!of! hand,”! thus!necessitating!early! assertion!of!parental! control.!As! such,!children’s! appeals! to! their! rights! may! make! the! situation! worse,! since! parents! may! interpret! these!appeals!as!a!sign!that!the!situation!has!already!escaped!their!control.560!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!554!Unofficial!translation!provided!by!Global!Initiative!to!End!All!Corporal!Punishment!of!Children,!Haiti&country&report!(February!2009).!Available!at!http://www.endcorporalpunishment.org/!!




557!Haitian!Ministry!of!Social!Affairs!and!Labor,!Response&to&the&United&Nations&Secretary5General’s&study&on&violence&against&children&questionnaire&to&governments!(March!9,!2005).!Available!at!http://www2.ohchr.org/english/bodies/CRC/docs/study/responses/Haiti.pdf!





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In! 2005,! the! government!of!Haiti! reported! to! the!UN!Study!on!Violence! against! Children! that! 40%!of!children!were!hit!or!beaten!when! they!behaved!badly,! and! that!14%!of! children! in!UNICEF’s!Voice!of!Children! survey! had! reported! living! in! a! family!where! there!were! scenes! of! aggression! and! violence,!primarily! between! the! adults! and! then! directed! at! the! child.! The! government! also! asserted! that! the!proportion! of! children! who! were! hit! or! beaten! when! they! behaved! badly! was! higher! among! rural!children! than! for! urban! children.561! Supporting! the! notion! that! corporal! punishment! in! the! home! is!normalized! in!Haiti,! the!government! further!noted! that!only!a!very!small!proportion!of! those!children!who!experienced!violence! in! the!household! included!this!criterion! in! their!evaluation!of! the!quality!of!their!relationships!with!their!parents.!!!Researchers! often! differentiate! between! the! biological! children! of! heads! of! household! and! child!domestic!workers,!which! include! paid! child! servants! and! those! referred! to! as! “restaveks.”!Numerous!reports! highlight! the! particularly! high! risks! of! physical! violence! experienced! by! restaveks,! (discussed!further!in!Section!9A.&Children&in&domestic&service&and&servitude).!Restavek!children!are!often!subjected!to! physical,! psychological! and! sexual! abuse! by! household! heads! and! their! biological! children.562,563!Among!the!many!causes!and!consequences!of! the!“restavek”&situation,! the!UN!“Report!of! the!Special!Rapporteur!on!contemporary!forms!of!slavery,! including! its!causes!and!consequences”!stated!that70%!of!restavek&children!in!domestic!servitude!in!2009!had!suffered!from!some!form!of!abuse.!Among!these!children,!about!10%`15%!had!been!sexually!abused!in!the!home.564!The!most!comprehensive!analysis!of!corporal!punishment! in!Haitian!households!was! conducted!by!FAFO! in!2002.!This! analysis! found! that,!contrary! to!prior! assumptions,! child! domestic!workers! did!not! experience! significantly! higher! rates! of!corporal! punishment! in! the! home! than! biological! children.! However,! the! use! of! corporal! punishment!was!shown!to!be!very!high!overall!(Figure!48!and!Figure!49).565!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!561!Haitian!Ministry!of!Social!Affairs!and!Labor,!Response&to&the&United&Nations&Secretary5General’s&study&on&violence&against&children&questionnaire&to&governments!(March!9,!2005).!Available!at!http://www2.ohchr.org/english/bodies/CRC/docs/study/responses/Haiti.pdf!


563!U.S.!Department!of!Labor,!Haiti,!Bureau!of!International!Labor!Affairs!(2011).!Available!at!http://www.dol.gov/ilab/media/reports/iclp/Advancing1/html/haiti.htm!!




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Figure.48:.Reported.methods.of.punishment.of.children,.by.sex.and.child.domestic.worker.(CDW).status,.2002.

!Source:!T.!Sommerfelt,!Child&domestic&labour&in&Haiti:&Characteristics,&contexts&and&organisation&of&children’s&

residence,&relocation&and&work,!FAFO!(May!2002).!Available!at!http://www.fafo.no/ais/other/haiti/childlabour/EEDH_Report_draft_english.pdf!!

!!Figure.49:.Percent.of.surveyed.children.punished.in.the.week.before.the.survey,.by.urban/rural.status,.sex,.and.child.domestic.worker.status,.2002.



!!Despite! finding!that! the!prevalence!of!corporal!punishment! is! relatively!equal!between!child!domestic!workers! and!other! children! in! the!household,! FAFO!noted! that!psychological! violence!appeared! to!be!more!prevalent!in!child!domestic!workers.!These!children!do!not!benefit!from!the!same!level!of!inclusion!

!


in! the!emotional! community!of! the! family!as!other! children.566! This! sense!of!being!an! “outsider”!may!both! increase! the! level! of! psychological! anguish! experienced! when! the! child! is! physically! or! verbally!reprimanded,!and!lower!their!ability!to!cope.!The!UN!Special!Rapporteur!on!Slavery!noted!that!“many!restaveks&suffer!from!serious!trauma!induced!by!mistreatment:!inferiority!complex,!fear!of!men,!fear!of!adults! and! incontinence!among!other! things.”567! Thus,!while!many! child!domestic!workers!experience!similar!rates!of!violence!in!the!home!as!biological!children,!the!psychological!effects!of!such!treatment!may!be!greater,!supporting!their!identification!as!a!vulnerable!group.!!In! cases! where! child! abuse! in! the! home! is! reported,! the! Haitian! National! Police’s! Brigade! for! the!Protection!des!Mineurs!(BPM)!intervenes!by!extracting!children!from!these!environments.!Due!to!lack!of!resources,! these! child! victims! are! often! held! in! the! same! room!with! children! in! conflict!with! the! law!before!being!transferred!to!the!protection!of!the!Institute!for!Social!Welfare!and!Research!(Institut&du&Bien5Être& Social& et& de& la& Recherche& or! IBESR),! raising! concerns! regarding! their! physical! and! mental!wellbeing.! Since! the! earthquake,! an! additional! 100! BPM! officers! have! been! trained! to! prevent! and!respond! to! cases! of! child! abuse! and! child! trafficking,568! though! it! is! unclear!whether! alternative! care!arrangements!are!now!made!for!victims!of!child!abuse.!In!addition!to!intervening!in!cases!of!child!abuse,!the! BPM! also! carries! out! community! sensitization! activities,! and! their! officers! are! trained! social!workers.569!!Despite!its!prohibition!in!2001,570!corporal!punishment!remains!prevalent!in!schools.!The!use!or!threat!of!violence! is!used!to!maintain!classroom!discipline,!with! the!presence!of!a!whip!or! large!ruler.!These!tools!often!serve!as!a!constant!threat!by!teachers!and!disciplinary!monitors!to!maintain!discipline,!even!if!they!are!never!used.!A!2008!report!by!Amnesty!International!asserted!that!children!in!Haiti’s!schools!remained! subject! to! beatings! and! food! deprivation,! as!well! as! insults! and! other! psychological! abuse.!Additionally,!young!girls!were!subject! to!sexual!abuse!by!teachers!and!administrative!staff.!They!were!often!then!forced!to!change!schools!due!to!the!stigma!that!follows!such!acts!of!violence.571!Despite!the!fact! that! children! rarely! question! the! use! of! violence! in! schools,! physical! and! psychological! abuse!







571!Amnesty!International,!Safe&schools:&Every&girl’s&right!(March!2008).!Available!at!http://www.amnesty.org/en/library/info/ACT77/001/2008!!

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negatively! affect! children’s!wellbeing.!Beyond! the!physical! ramifications,! such!abuse!also! curtails! self`esteem!and!expressive!abilities,!and!reinforces!feelings!of!failure.572!!Little! is! known! about! the! risks! of! violence! Haitian! children! face! in! detention! and! alternative! care.!Corporal!punishment!of!children!is! illegal! in!both!settings!under!the!law!of!September!2001.!However,!as! of! 2005! neither! codes! of! conduct! nor! disciplinary! commissions! to! monitor! and! prosecute! non`compliance!had!been!created.573!While!corporal!punishment!is!prohibited!both!as!a!sentence!for!a!crime!and! as! a! disciplinary! measure! in! prisons! and! alternative! care! facilities,! as! of! 2009! there! were! no!publically!available!estimates!of!the!prevalence!of!violence!against!children! in!either!penal! institutions!or!alternative!care!facilities.574!!Children!can!be!both!the!perpetrators!and!victims!of!violence!in!their!communities.!Communal!violence!in!Haiti!and!its!effects!on!children!are!intimately!related!to!political!conflict.!In!2006,!Haiti!experienced!an! unprecedented! increase! in! kidnappings! linked! to! political! groups! in! Cite! Soleil! and! other! hotspot!neighborhoods!that!had!previously!served!as!traditional!bases!for!one!of!Haiti’s!major!political!parties.575!During! this! period,! it! was! estimated! that! 600! children! were! members! of! armed! groups.! Meanwhile!political! violence! in! Cite! Soleil! resulted! in! the! deaths! of! at! least! 40! children! between! September! and!November!2005.576!Despite!sustained!efforts!to!disperse!gangs!and!restore!order!by!MINUSTAH!and!the!Haitian!National!Police!(HNP)!in!2007,577!disarmament!efforts!failed!to!block!the!easy!availability!of!small!arms.!In!2006,!the!World!Bank!estimated!that!there!were!around!200,000!weapons!in!civilian!hands.578!High!levels!of!gun!ownership!have!contributed!to!Haiti’s!high!rate!of!homicides;!in!2006,!there!were!an!estimated!34!homicides! for! every! 100,000! citizens,! 48%!higher! than! the! regional! average!of! 22.9! per!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!572!Haitian!Ministry!of!Social!Affairs!and!Labor,!Response&to&the&United&Nations&Secretary5General’s&study&on&violence&against&children&questionnaire&to&governments!(March!9,!2005).!Available!at!http://www2.ohchr.org/english/bodies/CRC/docs/study/responses/Haiti.pdf!







!


100,000! people.579! Availability! of! small! arms! remains! a! significant! contributor! to! persistent! endemic!violence.!!A!2009!PanÀmerican!Development!Foundation!study!of!households! in! troubled!urban!neighborhoods!of! Portàu`Prince,! Cap`Haïtien,! Gonaïves,! Saint`Marc,! and! Petit`Gôave! found! that! 6.7%! of! households!had!been!victimized!by!rape,!murder!and/or!kidnapping!in!the!18`month!period!May!2006!–!December!2007! in! troubled!urban!neighborhoods!of!Portàu`Prince,!Cap`Haïtien,!Gonaïves,!Saint`Marc!and!Petit`Gôave.!Political!conflict!was!centered! in!these!neighborhoods!during!that!period!(Figure!50).580!Survey!respondents! identified!armed!authorities!and!political!groups!as!the!main!perpetrators!of!the!majority!of!violence!in!Haiti.!It!is!worth!noting!that!1.2%!of!households!stated!that!one!or!more!members!of!their!households! had! been! involved! with! an! armed! group.! Higher! proportions! (15.62%)! of! households!victimized! by! aggression! were! found! in! Portàu`Prince! than! in! any! other! urban! area.! Saint`Marc!experienced!the! lowest!proportion!of!households!experiencing!violence!(4.03%)!(Figure!51).581!Though!Haiti!maintained!an!undercurrent!of!communal!violence!in!the!leadùp!to!the!January!2010!earthquake,!Oxfam! noted! that! the! 10!months! before! the! earthquake! were!marked! by! rising! incomes,! as! well! as!declines!in!kidnappings!and!unemployment.582!!Figure.50:.Percentage.of.households.affected.by.rape,.murder,.kidnapping.and.gang.involvement,.2006T2007.

Types.of.violations.Households.victimized.

by.violence.%.

Households.victimized.by.violence.

#.

Number.of.valid.responses.

N.

Rape! 1.8 26! 1,456!

Murder! 3.3 49! 1,456!

Kidnapping! 1.4 20! 1,456!Involvement!with!gangs! 1.2 18! 1,456!At!least!one!case!of!these!

violations!6.7 98! 1,456!

Source:!G.!R.!Smucker,!Y.!F.!Pierre,!and!J.!F.!Tardieu,!Lost&childhoods&in&Haiti:&Quantifying&child&trafficking,&restavèks,&&&victims&of&violence,!Pan!American!Development!Foundation!Protecting!Human!Rights!Project!(November!2009).!Available!at!http://www.crin.org/docs/Haiti_lost_childhoods.pdf!!




582!Oxfam!America,!Haiti:&A&once5in5a5century&chance&for&change,!Oxfam!Briefing!Paper!136!(March!2010).!Available!at!http://www.oxfamamerica.org/publications/haitiàònceìnà`century`chance`for`change!!

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!!Figure.51:.Percentage.of.households.with.victims.of.aggression,.by.city,.2006T2007.

!Source:!G.!R.!Smucker,!Y.!F.!Pierre,!and!J.!F.!Tardieu,!Lost&childhoods&in&Haiti:&Quantifying&child&trafficking,&restavèks,&&&victims&of&violence,!Pan!American!Development!Foundation!Protecting!Human!Rights!Project!(November!2009).!Available!at!http://www.crin.org/docs/Haiti_lost_childhoods.pdf!!

!!Young! people! crossing! the! border! to! the! Dominican! Republic! also! experience! high! risks! of! violence.!Fieldwork!by!FAFO!in!2009!revealed!that!young!Haitian!labor!migrants!are!exposed!to!a!range!of!threats!to! their!physical! safety!at! the!hands!of! their!employers,!Dominican!authorities,! and!border!guards,! in!addition! to! the! natural! hazards! involved! in! crossing! the! mountainous! border! with! the! Dominican!Republic.! In! the! Dominican! Republic,! young! Haitian! labor! migrants! have! reported! harassment! and!physical!abuse!by!employers,!as!well!as!robbery!during!their!crossing!and!stay.!Some!criminals!specialize!in!attacking! labor!migrants!during! their! return! to!Haiti,!when! they!are! carrying! their!earnings!back! to!their!households.!At!the!hands!of!their!new!employers,!these!migrants!risk!abuse!without!recourse!to!the! authorities! as! a! result! of! their! illegal! status! in! the! Dominican! Republic.583! Reports! of! abuse! by!Dominican! authorities,! including! by! border! officers! who! patrol! with! dogs,! are! well! known! to! young!Haitian! labor! migrants.! Those! detained! by! the! authorities! also! have! experienced! poor! conditions! of!detention!before!deportation,!including!confiscation!of!earnings.!Despite!the!risks!to!their!physical!and!mental! wellbeing,! however,! young! Haitians! continue! to! subject! themselves! to! these! risks! because!emigrating!appears!better!than!the!alternatives!of!poverty!and!stagnant!social!mobility! in!Haiti.584!This!topic!is!discussed!further!in!Section!9B.&Child&labor&migration&to&the&Dominican&Republic.!



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!Unfortunately,! lack!of! knowledge!and!a! subservient!position! in!Haitian!households! and! society!places!children!at!particularly!high!risk!of!violence.!They!are!both!less!likely!to!know!that!assistance!services!are!available! to! them! and! less! likely! to! use! these! services! because! of! established! family! and! community!pressures!and!norms.!A!2009!survey!found!that!a!very!low!proportion!of!adults!knew!where!they!could!find! services! for! victims! of! violence.!Only! 15%! of! the! 1,431! respondents! indicated! that! they! knew! of!available!services.585!Although!no!data!exists!on!the!issue,! it! is! likely!that!this!proportion!is!even!lower!for!children,!in!part!because!they!are!less!likely!than!adults!to!have!heard!about!these!organizations,!but!also!because!their!parents!are!often!the!perpetrators!of!the!violence!against!them.!!!

i..Crime.in.the.camps.!The! security! situation! in! Portàu`Prince! deteriorated!markedly! following! the! 2010! earthquake.! In! Cite!Soleil,! 14%!of! residents! reported! having! been! victimized! by! or! having!witnessed! violence!where! they!were! living! between! January! and! March! 2010.! The! leading! forms! of! violence! were:! beating! (27%),!fighting! (24%),! rape! (20%),! and! theft! (18%).586! Risks! of! violence! following! the! earthquake! were!compounded!by!many!factors,!including!the!availability!of!small!arms,!the!disarray!of!security!forces,!the!escape!of!over!4,000!inmates!from!the!prison!in!Portàu`Prince,!and!the!desperate!need!of!households!in!earthquakeàffected!areas.587,588!!Insecurity!in!camps!is!greater!than!in!non`camp!zones!in!earthquakeàffected!areas.!In!March!2010,!the!University!of!Michigan!and!Small!Arms!Survey!found!that!47%!of!camp!residents!in!Portàu`Prince!had!been! victims! of! property! crimes! since! the! earthquake,!while! 21%! had! been! threatened!with! physical!harm.! In! contrast,! the! survey! found! that! only! 2%! of! the! general! non`camp! population! had! been!threatened!with!physical!violence!over!the!same!period.589!!The! increased! sense! of! insecurity! among! camp! residents! appears! related! to! two! primary! factors:!occurrences!of!violence!and!property!crimes,!and!the!physical!arrangement!of!camp!spaces!that!expose!individuals,! particularly! children,! to! greater! risk.! Adequate! lighting! in! camp! spaces,! the! availability! of!latrines! within! camps,! and! the! lack! of! private! bathing! facilities! were! listed! as! the! primary! factors!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!585!G.!R.!Smucker,!Y.!F.!Pierre,!and!J.!F.!Tardieu,!Lost&childhoods&in&Haiti:&Quantifying&child&trafficking,&restavèks,&&&victims&of&violence,!Pan!American!Development!Foundation!Protecting!Human!Rights!Project!(November!2009).!Available!at!http://www.crin.org/docs/Haiti_lost_childhoods.pdf!!



588!IFRC,!Haiti&earthquake:&Operations&update&No.&1!(January!2010).!Available!at!http://www.ifrc.org/docs/appeals/10/MDRHT00801.pdf!!

589!UN!OCHA!Haiti,!Haiti:&Humanitarian&assessment&key&findings&No.&3,!5!April!2010!(April!2010).!Available!at!http://groups.google.com/group/assessmentshaiti/browse_thread/thread/71f3f127213f7a06!!

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affecting!perceptions!of! insecurity,!especially! for!women!and!girls.!As!a! result,!women!and!girls!often!restricted!their!movements!at!night.!Many!parents!expressed!fear!for!their!children’s!safety,!and!many!kept!their!children!within!the!shelter!at!all!times!unless!accompanied!by!an!adult.590!For!this!reason,!the!provision!of!adequate!lighting!in!camps!has!been!a!priority!for!camp!management!organizations.!!Threats!to!camp!security,!as! identified!by!residents,! included!rape!and!other!sexual!and!gender`based!violence,!physical! violence,! violence!against! children,! fighting,! and! theft.!Respondents!also!mentioned!concerns! surrounding! arguments! between! IDPs! and! the! owners! of! land! occupied! by! IDP! camps! (see!Section!6D.&Shelter&and&housing).!They!further!cited!concerns!regarding!drug!and!alcohol!abuse!and!the!presence! of! prisoners!who! had! escaped! as! a! result! of! the! earthquake.591! In!March! 2010,! the! Haitian!government!noted!that!the!camp!security!situation!was!deteriorating,!with!increasing!rates!of!property!crimes! and! gender`based! violence! (discussed! further! in! Section! 5C.& Sexual& and& gender5based&violence).592!!The! response! to! insecurity! in! camps! has! been! both! exogenous! and! endogenous.! In! many! instances,!camp!committees!and!security!brigades!formed!to!deal!with!security!issues,!and!have!been!credited!as!key! actors! in! reducing! insecurity! and! increasing! camp! stability.! In! addition,! they! provided! a! valuable!avenue! for! relief! workers! to! both! assess! camp! needs! and! deliver! a! timely! response.! However,! some!groups! also! have! been! accused! of! corruption,! abuse,! enflaming! camp! tensions,! and!misrepresenting!camp! information! for! personal! gain.! Nevertheless,! camp! committees! and! security! brigades! were!generally!perceived!to!have!a!positive,!stabilizing!influence.593!!In!March! 2010,!many! residents! noted! that! they! rarely! saw!MINUSTAH!or! the!HNP!within! the! camps.!Those!concerns!led!them!to!request!a!fixed!police!post!in!camps!and!foot!patrols!at!night.594!In!contrast,!the!HNP!stated! that!dozens!of!police!patrols!were!present! in! camps!every!day,! leading!MINUSTAH! to!conclude! that! the! disparities! between! the! reports! from! the! HNP! and! the! camp! residents!meant! that!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!590!UN!MINUSTAH,!IDP&camp&joint&security&assessment&report,!MINUSTAH!Human!Rights!Section!(March!2010).!Available!at!http://oneresponse.info/Disasters/Haiti/Protection/publicdocuments/Joint%20Security%20Assessment%20report%20`%20Final.doc!!


592!Government!of!Haiti,!Haiti&earthquake&PDNA:&Assessment&of&damage,&losses,&general&and&sectoral&needs!(March!2010).!Available!at!http://siteresources.worldbank.org/INTLAC/Resources/PDNA_Haiti`2010_Working_Document_EN.pdf!!



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police!patrols!were!not! visible! even!when!present.! These!uncertainties! have!heightened! the! sense!of!insecurity!among!camp!residents!and!compromised!the!deterrence!of!crimes.595!The!Haitian!government!conceded! that! the! presence! of! police! authorities! in! camps! was! insufficient,! but! also! noted! that! the!police!force!was!significantly!restricted!by!human!and!material!losses!stemming!from!the!earthquake.596!Many! recruits,! even! when! deployed,! did! not! have! the! necessary! equipment! (such! as! weapons! or!flashlights)!to!fulfill!the!daunting!challenge!of!ensuring!the!rule!of!law!in!post`earthquake!Haiti.597!!!Threats! to! security!were!also! associated!with! the!distribution!of!humanitarian! aid.! The! impact!of! this!factor! is! likely! to!be! less!on!children! than!adults!because!children!are! rarely! responsible! for!collecting!distribution! packages.! However,! it! is! important! to! consider! the! ability! of! children! to! access! food!distributions!without!parental!care.!A!survey!by!World!Vision!in!March!2010!found!that!one!quarter!of!respondents! identified! risks! to! safety!and! security!as!a! result!of! food!distributions.!The! three!primary!concerns! were! fighting! when! distributions! were! insufficient! for! the! needs! of! all! families,! violence! at!distribution! points! attributable! to! the! lack! of! police! security! presence,! and! fighting! when! non`camp!residents! entered! camps! to! receive! distributions! intended! for! camp! residents.598! The! International!Federation!of!Red!Cross!and!Red!Crescent!Societies!(IFRC)!noted!an!increase!in!violence!and!looting!in!the! first! days! of! the! disaster! due! to! the! desperation! of! vulnerable! groups! to! meet! basic! needs.599!However,!a!July!2010!UN!report!stated!that!claims!of! looting!and!violence!following!the!disaster!were!largely! overblown! by! the! international! media! and! that! rates! were! far! lower! than! reported.600! In! the!months! following! the! earthquake,! food! distribution! became! more! organized! as! a! result! of! better!information! and! the! consolidation! of! logistic! supply! chains.! Accordingly,! reports! of! violence! quickly!subsided,! and! security! concerns! related! to! aid! distribution! appeared! to! become! a! peripheral! security!issue.!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!595!UN!MINUSTAH,!IDP&camp&joint&security&assessment&report,!MINUSTAH!Human!Rights!Section!(March!2010).!Available!at!http://oneresponse.info/Disasters/Haiti/Protection/publicdocuments/Joint%20Security%20Assessment%20report%20`%20Final.doc!!




599!IFRC,!Haiti&earthquake:&Operations&update&No.&1!(January!2010).!Available!at!http://www.ifrc.org/docs/appeals/10/MDRHT00801.pdf!!

600!Cited!in!ALNAP,!Haiti&earthquake&response:&Context&analysis!(July!2010).!Available!at!http://www.alnap.org/pool/files/haiti`context`analysis`final.pdf!!

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C.&Sexual&and&genderLbased&violence&!High! levels! of! sexual! and! gender`based! violence! (SGBV)! are! endemic! in! Haiti.! The! January! 2010!earthquake!has!further!intensified!the!risk!of!abuse,!as!pre`existing!safety!nets!and!prevention!strategies!were!rendered!inoperable.!Specific!sub`groups!with!elevated!risk!can!be!identified,!including!children!in!domestic!servitude,!street!children,!child!commercial!sex!workers,!and!labor!migrants!to!the!Dominican!Republic.!Victims!of!SGBV!overwhelmingly!lack!access!to!legal!recourse!and!medical!services,!deepening!their!vulnerability!to!adverse!outcomes!and!reinforcing!the!perception!of!perpetrator!impunity.!!!Following! the! fall! of! the!Duvalier! era,! rape! and! other! forms! of! sexual! violence!were! used! as! tools! of!repression! against! women! and! girls! in! the! military! regime.! The! Ministry! of! Women’s! Affairs! and!Women’s!Rights!recorded!1,500!cases!of!sexual!abuse!and!aggression!against!girls!aged!6`15!between!1994! and! 1999.601,602! However,! a! 1996! UNICEF`funded! household! study! suggests! that! this! figure!significantly!underestimates!the!scale!of!victimization.!The!study!found!that!46%!of!young!girls!had!been!sexually!abused!during! their! lifetime,!and! that!33%!of! those!abuses!had!been!committed!against!girls!aged! 5`9! while! 43%! were! committed! against! girls! aged! 10`14.! The! survey! also! revealed! that! an!overwhelming! 70%! of! Haiti’s! female! population! had! experienced! some! form! of! violence! over! their!lifetime.!Of!these,!approximately!37%!involved!sexual!violence!and!48%!involved!physical!violence.!The!study! further! noted! that! half! of! all! cases! of! physical! violence! against!Haitian!women!occurred! at! the!hands!of!an!intimate!partner.603!!!While!consistent!and!reliable!estimates!of!violence!against!Haitian!women!do!not!exist,!it!is!possible!to!discern! potential! trends! over! time.! Taken! together,! studies! show! that! the! prevalence! of! SGBV! has!changed! very! little! over! the! past! two! decades.! In! 2000,! the! study! of! a! non`representative! sample! of!sexually! active! youths! aged! 15`24! in! Haiti! showed! that! 22%! of! females! and! 15%! of! males! had! ever!experienced! sexual! violence!over! their! lifetimes.604! The!nationally! representative!EMMUS! III! survey!of!the!same!year!indicates!a!higher!occurrence!of!SGBV!against!women,!reporting!that!35%!of!women!over!the! age! of! 15! had! experienced! physical! violence! in! the! year! preceding! the! survey,! with! greater!prevalence! in! rural! areas! (41%)! than! in! urban! areas! (34%).605! Another! survey! in! 1999! found! that!domestic! violence! was! the!most! common! form! of! violence! against! women,! and! that! 29%! of! Haitian!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!601!Amnesty!International,!Don’t&turn&your&back&on&girls:&Sexual&violence&against&girls&in&Haiti!(2008).!Available!at!http://www.amnesty.org/en/library/asset/AMR36/004/2008/en/f8487127`b1a5`11dd`86b0`2b2f60629879/amr360042008eng.pdf.!

602!OMCT,!Rights&of&the&child&in&Haiti!(October!2002).!Available!at!http://www.omct.org/files/2001/11/1155/haitichildren2002.pdf!!

603!Cited!in!World!Bank,!A&review&of&gender&issues&in&the&Dominican&Republic,&Haiti&and&Jamaica,!Report!No.!21866`LAC!(2002).!Available!at!http://www`wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2003/03/22/000094946_03030704005682/Rendered/PDF/multi0page.pdf!!

604!A.!M.!Gomez,!I.!S.!Speizer,!and!H.!Beauvais,!“Sexual!violence!and!reproductive!health!among!youth!in!Port`au`Prince,!Haiti,”!Journal&of&Adolescent&Health!44!(2000),!pp.!508`510.!


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women!had!experienced!domestic!violence!in!the!preceding!year,!while!13%!of!women!were!found!to!have!experienced! two!or!more! forms!of! violence!over! the! same!period.606,607!Asserting! the! continued!risk!of!SGBV!faced!by!young!girls,!the!Committee!on!the!Rights!of!the!Child!reported!in!2003!that!more!than!one!third!of!Haitian!women!had!been!sexually!abused!before!age!15.608,609!!!One! of! the!more! troubling! pieces! of! data! to! arise! during! this! period!was! UNICEF’s! 2000! finding! that!there!existed!a!significant!association!between!early!marriage!and!intimate!partner!violence.!At!the!time!of!the!report,!they!noted!that!25%!of!married!girls!aged!15`19!had!experienced!some!form!of!intimate!partner!violence,!and!that!“younger!women!and!women!who!married!at!the!earliest!ages!reported!the!most! intimate! partner! violence.”610! This! conclusion! is! of! particular! concern! as! the! prevalence! of! child!marriage!in!Haiti!has!continued!to!increase!over!the!past!decade,!surpassing!30%!in!2006!(See!Section!3D.&Child&marriage).611!!

!Political! violence! surrounding! the!exile!of!President!Aristide! in!2004! led! to!a! surge! in! sexual! violence,!particularly!in!urban!areas.612!During!this!period,!the!prevalence!of!gang!rapes!also!increased,!with!NGOs!estimating!that!33%!of!all!rapes!were!perpetrated!by!two!or!more!assailants.613!!Armed!groups!used!rape!as!a!weapon!to!terrorize!the!population.614!The!2005`2006!EMMUS!IV!survey!provided!a!nationally!representative!snapshot!of!gender`based!violence!at!the!height!of!this!civil!unrest.!The!survey!found!that!27%!of!women!over!age!15!had!experienced!physical!violence!over!their!lifetime,!and!that!16%!of!these!cases!had!occurred!in!the!preceding!12!months.! In!64%!of!cases,!husbands!and!other!partners!were!cited!as!the!perpetrators.!Regrettably,!the!prevalence!of!domestic!violence!did!not!improve! significantly! from! the! 2000! EMMUS! III! survey,! with! roughly! a! quarter! of! married! women!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!606!World!Bank,!Social&resilience&and&state&fragility&in&Haiti:&A&country&social&analysis,!Caribbean!Country!Management!Unit,!Report!no.!36069`HT!(April!2006).!Available!at!http://siteresources.worldbank.org/SOCIALANALYSIS/1104894`1115795935771/20938696/Haiti_CSA.pdf!

607!A.!J.!Gage,!“Women’s!experience!of!intimate!partner!violence!in!Haiti,”!Social&Science&&&Medicine!61/2!(2005),!pp.!343`364.!








614!Amnesty!International,!Don’t&turn&your&back&on&girls:&Sexual&violence&against&girls&in&Haiti!(2008).!Available!at!http://www.amnesty.org/en/library/asset/AMR36/004/2008/en/f8487127`b1a5`11dd`86b0`2b2f60629879/amr360042008eng.pdf!

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reporting!domestic! abuse.! Six!percent!of!women! reported!having!experienced!physical! violence!while!pregnant.615!!!Based! on! the! available! data,! it! is! evident! that! far! more! women! and! girls! experience! gender`based!violence!than!report!it.!UNICEF!observed!that!only!4,000!cases!of!gender`based!violence!were!recorded!in!SudÈst,!Ouest,!Artibonite,!and!Grande‘Anse!Departments!between! January!2006!and! June!2007.616!Though! high! in! absolute! terms,! these! values! are! far! lower! than! would! be! expected! if! prevalence!estimates! derived! from! the! EMMUS! IV! survey! were! applied! to! the! populations! in! each! of! these!Departments.!!Other! studies! conducted! in! 2006! also! revealed! high! rates! of! sexual! violence! towards! girls.! In! the! 22`month! period! between! February! 29,! 2004! and! December! 2005! following! the! departure! of! President!Aristide,!a!Lancet!study!estimated!that!approximately!3.1%!of!all!females!in!the!greater!Portàu`Prince!area!were! sexually! assaulted! (35,000! girls! and!women),! including! almost! one! in! every! 20! girls! (4.6%)!younger! than! 18! years.617! The! authors! estimated! that! 1! in! 40! girls! in! Portàu`Prince! were! sexually!assaulted! each! year! and! that! girls! under! age! 18! accounted! for! more! than! half! (53.1%)! of! all! sexual!assault!victims!in!the!capital.!Of!the!victims!surveyed!in!this!study,!32%!were!aged!11`17,!and!16%!were!aged!10!or!younger,!suggesting!that!approximately!13,000!girls!aged!10`17!and!5,600!girls!aged!less!than!10! were! sexually! assaulted! in! the! 22! months! following! President! Aristide’s! departure.618! This! age!breakdown! of! Haitian! sexual! assault! victims! is! roughly! equivalent! to! that! found! by! service! provision!organizations.!Kay!Fanm!reported!that!55%!of!those!who!sought!care!at!their!facilities!were!aged!18!or!younger,! and!Haitian!Women’s! Solidarity! (Solidarité! Fanm!Ayisien,! SOFA)! reported! that! girls!under!18!accounted!for!50%!of!those!seeking!service.619,620!UNICEF!found!a!similar!age!pattern!in!2006,!with!47%!of!all!sexual!assault!victims!being!girls!under!the!age!of!18.621!!Analysis!of!2006!EMMUS!IV!data!also!found!a!high!prevalence!of!sexual!abuse!across!all!Departments,!with! Portàu`Prince! witnessing! the! lowest! prevalence! of! forced! first! sex! (18.5%),! and! the! Ouest!Department!exhibiting!the!lowest!prevalence!of!spousal!forced!sex!(3.7%)!(Figure!52).!At!the!time!of!the!survey,! 10.8%!of! female! youth! aged!15`24! reported!having!been! forced! to! participate! in! a! sexual! act!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!615!Government!of!Haiti,!Enquête&mortalité,&morbidité&et&utilisation&des&services&(EMMUS&IV)&200552006!(January!2007).!Available!at!http://www.measuredhs.com/pubs/pdf/FR192/FR192.pdf!

616!UNICEF!Executive!Board,!Revised&country&programme&document:&Haiti&(200952011)!(2009).!Available!at!http://www.unicef.org/about/execboard/files/Haiti`FRS2009`revised_feb2010Ènglish.pdf!




620!UN!GA,!Situation!of!human!rights!in!Haiti,!UN!Doc.!A/HRC/4/3!(2007).!Available!at!http://www.unhcr.org/refworld/docid/461f2e552.html!!


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with!their!spouse,!with!greater!prevalence! in!urban!areas!(12.7%)!than! in!rural!areas!(8.8%).!Critically,!24.2%! of! all! female! youth! reported! that! their! first! sexual! encounter! had! been! forced,! with! the!prevalence!of!forced!first!sex!slightly!higher!in!rural!areas!(25.9%)!than!in!urban!areas!(22.5%).622!!Figure.52:.NonTconsensual.sex.among.15T24.year.old.females,.by.Department.and.urban/rural.status,.2006.



!!Assessments! of! SGBV! after! 2006! have! not! been! nationally! representative,! further! complicating! trend!analyses.!A!2009!study!found!that!rape!was!no!longer!employed!as!a!political!tool!to!the!same!extent!as!



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earlier! in!the!decade.623!This!decline!also!may!have!affected!the!observed!decline! in!the!proportion!of!rapes! committed! by! more! than! one! perpetrator.! However,! following! the! 2008! hurricane! season,!occurrences!of!rape!and!other!forms!of!sexual!violence!were!thought!to!have!increased,!as!is!often!the!case!following!disasters.624,625!A!survey!conducted!in!2008!found!that!44%!of!pregnant!women!seeking!prenatal!care!at!community!health!centers!in!Artibonite!reported!that!they!had!experienced!violence!in!the! preceding! six! months.! In! 77.8%! of! these! cases,! the! violence! was! perpetrated! by! an! intimate!partner.626!These!findings!suggest!that,!while!the!elevated!rates!of!SGBV!attributable!to!civil!unrest!and!political!conflict!had!fallen!before!the!January!2010!earthquake,!Haitian!women!and!girls!continued!to!face!significant!risks!at!the!hands!of!strangers!and!intimate!partners.!!There! is! a! widely`held! perception! among! policy`makers! and! service! providers! that! the! prevalence! of!SGBV! increased! following! the! 2010! earthquake.627,628,629,630,631,632,633,634! While! there! have! been! no!nationally! representative! surveys! to! enable! the!quantification!of! this! increase,! available! evidence! and!experience! in!other!post`disaster! contexts!do! suggest! that! it!has!occurred.! In!addition,! it! is! likely! that!greater!proportions!of!victims!are!now!reporting!abuses!due!to!greater!accessibility!of!care!and!support!services.635!A!randomized!survey!of!households!in!Port`au`Prince!in!February!and!March!of!2010!found!that!3%!of!all!people!in!Port`au`Prince!had!been!victimized!by!sexual!assault!in!the!1`2!months!following!




626!M.!J.!Small,!J.!Gupta,!R.!Frederic,!et!al.,!“Intimate!partner!and!nonpartner!violence!against!pregnant!women!in!rural!Haiti,”!International&Journal&of&Gynecology&and&Obstetrics!102!(2008),!pp.!226`231.!











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the!earthquake,!and!that!all!but!one!respondent!was!female.!Half!of!those!who!reported!sexual!abuse!in!this! survey! were! under! the! age! of! 18.! Victims! identified! perpetrators! as! “criminals,”! rather! than! as!neighbors,!friends!or!spouses.636!This!finding!was!supported!by!another!survey!in!July!2010,!which!found!that!most!rapes!were!undertaken!by!people!unknown!to!the!victim,!and!were!usually!attributed!to!two!or! more! armed! individuals! who! were! members! of! neighborhood! gangs! or! escaped! prisoners.637!According! to! UN! OCHA! in! March! 2010,! rape! constituted! 20%! of! all! violence! in! Cite! Soleil,! and! was!attributed!in!large!part!to!the!absence!and!ineffectiveness!of!security!forces.638!!A!study!conducted!by!the!Center!for!Human!Rights!and!Global!Justice!at!the!New!York!University!School!of! Law! in! January! 2011! highlighted! the! continuing! threat! of! SGBV! in! IDP! camps! one! year! after! the!earthquake.!As!the!authors!noted,!prevalence!estimates!may!not!be!generalizable!to!all! IDP!camps,!as!the! survey! was! conducted! in! only! four! camps! within! Port`au`Prince,! but! they! may! offer! valuable!guidance!in!terms!of!patterns!and!trends.!The!study!found!that!over!the!one`year!period!following!the!earthquake,!14%!of!respondents!reported!either!the!rape,!unwanted!touching,!or!both,!of!one!or!more!household!members;!9%!of!respondents!reported!that!a!member!of!their!household!had!been!raped!or!otherwise!forced!to!have!sex,!8%!had!been!the!victims!of!unwanted!touching,!and!3%!had!experienced!both!unwanted!touching!and!rape.!Of!those!respondents!who!provided!the!gender!of!the!victim,!74%!reported!the!victim!to!be!a!woman!in!their!household,!12%!reported!the!victim!as!a!girl!under!age!18!(combined! girls! and! women! constituted! 86%! of! victims! with! reported! gender),! 9%! of! victims! were!reported! to!be!men,! and!5%!of! victims!were! reported! to!be!boys.! The! study!authors!note! that! these!proportions! are! likely! to! be! underestimates! due! to! shame! and! stigma! associated! with! SGBV!victimization,! in! addition! to! lack! of! knowledge! of! victimization! of! other! household! members! and! a!reluctance!to!report!SGBV!committed!by!members!within!the!household.639!!Fear! of! sexual! and! gender`based! violence! remained! prevalent! one! year! after! the! earthquake! among!households!in!the!four!surveyed!IDP!camps.!Approximately!60%!of!respondents!reported!being!afraid!of!sexual!or!gender`based!violence! for! themselves!or! for!others! in! their!household,!with! little!difference!between!male!and!female!respondents.!Approximately!70%!of!respondents!stated!that!they!were!more!worried! about! SGBV! than! they! had! been! before! the! earthquake,! with! differences! observed! between!female! (72%)! and! male! (61%)! respondents.! Seven! percent! of! female! respondents! and! 13%! of! male!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!636!A.!R.!Kolbe,!R.!Muggah,!R.!A.!Hutson,!et!al.,!Assessing&needs&after&the&quake:&Preliminary&findings&from&a&





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respondents!reported!comparable!concerns!of!SGBV!victimization!compared!to!before!the!earthquake,!while!20%!of!females!and!26%!of!males!reported!feeling!less!worried.640!!Camp!security!and!organization!were!universally! cited!as! factors! impacting! the!prevalence!of!SGBV! in!camps!following!the!earthquake.!As!noted!previously,!adequate!lighting!in!common!camp!spaces,!such!as!around!latrines!and!bathing!facilities,!was!consistently!identified!by!stakeholders!and!respondents!as!a!key!determinant!of!SGBV!risk,641,642,643,644,645!and!many!young!women!said!that!they!felt!vulnerable!and!restricted! their!movement! to! these! unlit! areas! at! night! for! fear! of! being! attacked.646! The! absence! of!security!personnel!patrolling!camps!also!increased!the!vulnerability!of!female!camp!residents,!and!many!women!organized!their!own!security!brigades!to!escort!girls!and!women!to!the!bathroom!at!night!and!groups!of!men! to!patrol! camp!areas.!The! loss!of!male! family!members! in! the!earthquake,!who!would!traditionally!have!protected!girls!and!women!in!the!family,!has!also!increased!the!sense!of!insecurity!in!camps.647!The!majority!of!sexual!violence!in!camps!has!occurred!between!9!pm!and!3!am!in!the!streets,!in! tents,!or! in!public! spaces.648,649,650!Thus,! the!protection!of!children!and!women!from!SGBV! in!camps!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!640!Center!for!Human!Rights!and!Global!Justice,!Sexual&violence&in&Haiti’s&IDP&camps:&Results&of&a&household&study,!New!York!University!School!of!Law!(March!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Child%20Protection/studies%20reseaches%20evaluation%20books/Haiti%20Sexual%20Violence%20March%202011.pdf!!






645!Amnesty!International,!Haiti:&After&the&quake,!Initial!Mission!Findings!(March!2010).!Available!at!http://www.amnesty.org/en/library/asset/AMR36/004/2010/en/d12e3cdc`2103`40b8`af57`1412dcf3d413/amr360042010en.pdf!






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will!require!a!multi`faceted!approach,!including!aspects!of!camp!organization!and!management,!greater!visible!presence!of!security!personnel,!and!support!for!organically!created!initiatives!by!camp!residents.!!The!Center!for!Human!Rights!and!Global!Justice!survey!also!found!correlations!between!SGBV!and!food!insecurity!and!camp!management!status.!Those!reporting!household!SGBV!victimization!were!less!likely!than! other! households! to! report! having! eaten! every! day! during! the!week! preceding! the! survey.! The!results! of! the! study! also! supported! the! assertion! that! SGBV! was! more! prevalent! in! unmanaged! IDP!camps!than!in!those!with!an!official!camp!management!agency.!Though!the!limited!survey!sample!size!hampers! generalizability,! the! finding! that! 18%! of! households! in! one! surveyed! unmanaged! camp! had!experienced! SGBV!while! 10%!of! those! in! a!managed! camp!had! similar! experiences!may! highlight! the!importance! of! camp! management! agencies! in! preventing! SGBV,! especially! given! that! 50%! of! camps!remained!unmanaged!in!January!2011.651!In!addition,!some!sources!have!highlighted!the!impact!of!cash`for`work!interventions!designed!to!provide!income!assistance!for!IDPs!on!SGBV!prevalence.!In!cash`for`work! interventions,!money! is!typically!placed! in!men’s!hands,!thus! leaving!female! IDPs! in!a!vulnerable!state,!and!contributing!to!“survival!sex”!and!prostitution.652!!Lack!of!access!to!basic!needs!(including!work,!food,!etc.)!following!the!earthquake,!has!raised!concerns!among!many!non`governmental!organizations!(NGOs)!that!survivors,!especially!women!and!girls,!were!resorting! to! negative! coping! strategies,! such! as! transactional! sex,! to! fulfill! their! needs.653! The!Haitian!Government’s! Post`Disaster! Needs! Assessment! (PDNA)! shows! these! concerns! to! be! well`founded.654!Though! prevalence! estimates! are! not! available,!many! young!women! have! reportedly! been! forced! to!negotiate! sexual! favors! in! order! to! access! food! and! shelter,! and! have! increasingly! used!“transactional/survival!sex”!since!the!earthquake.655,656,657!The!use!of!transactional!sex!was!reported!in!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!650!Center!for!Human!Rights!and!Global!Justice,!Sexual&violence&in&Haiti’s&IDP&camps:&Results&of&a&household&study,!New!York!University!School!of!Law!(March!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Child%20Protection/studies%20reseaches%20evaluation%20books/Haiti%20Sexual%20Violence%20March%202011.pdf!!







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all!15!focus!groups!conducted!during!UNHCR’s!January`March!2011!study!of!Port`au`Prince!IDP!camps.!Women!were!found!to!have!engaged!in!transactional!sex!to!meet!their!own!needs,!as!well!as!those!of!their!children!and!household,!especially!in!cases!of!food!scarcity.!Of!the!women!who!reported!engaging!in!transactional!sex!in!2011,!none!reported!using!this!coping!strategy!prior!to!the!2010!earthquake,!and!all! expressed! distaste! for! what! they! were! doing.! The! UNHCR! noted! the! “harrowing”! context! of!transactional!sex!in!IDP!camps,!observing!that!“the!women!assessed!their!daily!needs!at!a!meager!10`25!Haitian! gourdes! (US$0.25! `! US$0.60)! per! day!—! a! far! cry! from! the! legal!minimum!daily!wage! of! 200!Haitian! gourdes! (US$5.000).”658! The! study! also! highlighted! the! failure! of! response! organizations! to!follow!best!practices!in!food!distribution!and!interventions!intended!to!broaden!access!—!and!how!this!failure! contributed! to! the!perpetuation!and!exacerbation!of!women!engaging! in!high`risk!practices! to!meet!their!basic!needs.659!!Within! the! female! population,! a! number! of! subgroups! can! be! identified! who! are! at! elevated! risk! of!SGBV.! These! include! female! child! domestic! servants,! street! children,! young! labor! migrants,! and!commercial! sex! workers.! Female! child! domestic! servants,! often! referred! to! by! the! pejorative! term,!“restavek,”! are! at! a! greater! risk! of! sexual! abuse! than! male! child! domestic! servants! and! the! general!female!population.!A!2006!Lancet!study!found!that!female!child!domestic!servants!were!4.5!times!more!likely!to!be!sexually!abused!than!other!girls.!They!further!deduced!that!1! in!every!19!female!restaveks!was!sexually!assaulted!each!year.!Ultimately,!female!child!domestic!servants!represented!“36.2%!of!all!sexual! assault! victims! and! 68.0%! of! child! victims! of! sexual! assault.”660! In! 2009,! the! UN! Special!Rapporteur!on!contemporary!forms!of!slavery,!including!its!causes!and!consequences,!found!that!of!the!70%!of!girl!domestic!servants!who!reported!some!form!of!abuse,!10`15%!reported!being!sexually!abused!by!the!head!of!household!or!other!children!in!the!family.661!The!U.S.!Labor!Department!has!also!noted!that!if!a!domestic!servant!becomes!pregnant,!she!is!typically!expelled!from!the!household.662!!There!is!a!widespread!perception!that!females!who!migrate!to!the!Dominican!Republic!in!search!of!work!will!become!prostitutes,!making!labor!migration!a!less!attractive!option!for!girls!than!boys!(See!Section!9B.&Child&labor&migration&to&the&Dominican&Republic).!While!only!a!small!proportion!of!girls!who!migrate!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!657!UNHCR,!Driven&by&desperation:&Transactional&sex&as&a&survival&strategy&in&Port5au5Prince&IDP&camps!(May!2011).!Available!at!http://haiti.humanitarianresponse.info/LinkClick.aspx?fileticket=w`7_7C8C`2o%3d&tabid=81&mid=1413!!

658!UNHCR,!Driven&by&desperation:&Transactional&sex&as&a&survival&strategy&in&Port5au5Prince&IDP&camps!(May!2011).!Available!at!http://haiti.humanitarianresponse.info/LinkClick.aspx?fileticket=w`7_7C8C`2o%3d&tabid=81&mid=1413!!

659!UNHCR,!Driven&by&desperation:&Transactional&sex&as&a&survival&strategy&in&Port5au5Prince&IDP&camps!(May!2011).!Available!at!http://haiti.humanitarianresponse.info/LinkClick.aspx?fileticket=w`7_7C8C`2o%3d&tabid=81&mid=1413!!




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to!the!Dominican!Republic!work!as!prostitutes,!a!number!of! factors!aggregate!to! increase!their!risk!of!SGBV.!First,!young!female!labor!migrants!generally!work!“hidden”!as!servants!in!Dominican!households,!making! them!more! vulnerable! than!male!migrants! who! work! in! construction,! on! plantations,! and! in!other!more!visible!contexts.!Second,!many!migrant!girls!are!forced!to!perform!sexual!acts! in!exchange!for!“favors”!that!allow!them!to!find!work.!Finally,!when!crossing!the!frontier!to!the!Dominican!Republic,!Haitian!girls!risk!sexual!violence!from!armed!authorities!and!bandits.663!While!no!reliable!estimates!exist!on!the!extent!of!prostitution!and!sexual!violence!against!young!female!Haitian!labor!migrants,!the!threat!of! abuse! and! the! social! stigma! associated!with! female!migration!mean! that! far! fewer! girls! than! boys!migrate!to!the!Dominican!Republic.664!!No!estimates!exist!on!the!number!of!child!commercial!sex!workers!in!Haiti!before!or!after!the!January!2010!earthquake.!Commercial!child!sexual!exploitation!is!one!of!the!most!heinous!forms!of!child!labor,!and!is!defined!as!the!sexual!abuse!of!a!child!by!an!adult!in!exchange!for!pay!or!access!to!services.665!A!2003!study!by!ILO`IPEC!found!that!most!Haitian!child!commercial!sex!workers!were!between!ages!13`17,!with!some!as!young!as!9!or!10!years!old.666!The!rise! in!transactional!sex! in!exchange!for!food,!shelter,!and!other!basic!amenities!is!of!particular!concern!in!the!attempt!to!guarantee!child!protection!following!the!earthquake.667,668!!As! with! other! population! sub`groups,! there! is! very! little! information! on! the! extent! of! sexual! abuse!against!street!children.!Due!to!the!methodological!challenges!and!the!hidden!nature!of!this!population,!those! estimates! that! do! exist! may! be! unreliable.! However,! a! 2003! survey! by! the! Center! for! Popular!Education! uncovered! a! dire! situation! for! Haiti’s! female! street! children,! with! 70%! reporting! sexual!violence! over! their! lifetimes.669! Unfortunately,! the! impact! of! the! January! 2010! earthquake! on! this!population’s!vulnerability!remains!unknown.!!!SGBV! in! Haiti! occurs! against! a! backdrop! of! widespread! tolerance! for! and! justification! of! such! abuse.!According!to!the!EMMUS!IV!survey!of!2005`06,!35.8%!of!female!youth!(ages!15`24)!believed!that!wife!








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beating!was!justified!under!at!least!one!condition!(Figure!53).670!The!two!most!common!reasons!used!to!justify!violence!against!a!spouse,!according!to!surveyed!female!youths,!were!“if!wife!goes!out!without!husband”!(25.2%)!and!“if!wife!neglects!kids”!(25.8%).!Rural!respondents!were!more!likely!to!report!that!wife! beating! was! justified! across! all! conditions,! although! there! were! significant! differences! between!Departments.671!A!2004!survey!by!the!Haitian!Government!revealed!a!similarly!troubling!situation,!with!80%! of! men! believing! that! violence! against! a! woman! is! purely! a! family! matter,! with! a! significant!proportion!believing!that!domestic!violence!was!justified!in!some!cases.672!!

Figure.53:.Female.attitudes.toward.domestic.violence,.by.condition,.Department.and.urban/rural.status,.2006.








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!!A!number!of!pre`!and!postèarthquake!factors!have!been!found!to!increase!the!risk!of!SGBV!for!Haitian!children.! Analyses! conducted! prior! to! the! 2010! earthquake! found! that! age! discrepancies! between!partners! placed! young! girls! at! higher! risk! of! sexual! and! domestic! violence,! decreasing! their! ability! to!negotiate! safe,! protected,! voluntary! sexual! relations.673! Internalization! of! gender! relations! has! also!meant! that! children!who!have!witnessed! sexual! and/or! gender`based! violence! in! their! household! are!more!likely!to!accept!or!practice!violence!within!their!own!relationships.!This!phenomenon!results!in!the!inter`generational! perpetuation! of! abuse674,675! and! is! particularly! concerning! given! that! 20%! of!households!with!a!child!in!primary!school!reported!that!the!wife!had!been!beaten!in!front!of!the!child.676!Preèarthquake!risk!factors!also!included!neighborhood`level!poverty!and!male!unemployment,!number!of! children,! female! acceptance! of! gender`based! violence,677! length! of! time! in! the! relationship,678! and!sense!of! security! at!home.679!Women’s!economic! independence!and! self`reported! relationship!quality!were!identified!as!two!protective!factors!for!SGBV.680!!Sexual! and! gender`based! violence! entails! a! multitude! of! adverse! outcomes,! especially! for! children.!Principally,!children!who!experience!sexual!violence! in!Haiti!are!more! likely! to!become!pregnant!or! to!contract! sexually! transmitted! diseases,! and! are! at! greater! risk! of! these! outcomes! than! the! adult!population.681,682,683,684,685!Furthermore,!sexually!abused!children!are!more!likely!to!drop!out!of!school!or!



674!UNICEF,!The&state&of&Latin&American&and&Caribbean&children&2008:&Child&survival!(May!2008).!Available!at!http://www.unicef.org/publications/files/SOLAC_2008_EN_041408.pdf!




678!M.!C.!Smith!Fawzi,!W.!Lambert,!J.!M.!Singler,!et!al.,!"Factors!associated!with!forced!sex!among!women!accessing!health!services!in!rural!Haiti:!Implications!for!the!prevention!of!HIV!infection!and!other!sexually!transmitted!diseases,"!Social&Science&&&Medicine!60/4!(2005),!pp.!679`689.!



681!A.!M.!Gomez,!I.!S.!Speizer,!and!H.!Beauvais,!“Sexual!violence!and!reproductive!health!among!youth!in!Portàu`Prince,!Haiti,”!Journal&of&Adolescent&Health!44!(2000),!pp.!508`510.!



684!UNICEF,!The&state&of&Latin&American&and&Caribbean&children&2008:&Child&survival!(May!2008).!Available!at!http://www.unicef.org/publications/files/SOLAC_2008_EN_041408.pdf!

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endure!physical!injury.686,687!SGBV!can!also!have!a!serious!impact!on!children’s!mental!and!psychosocial!development! and! functioning.! Many! withdraw! from! daily! activities,! become! less! able! to! deal! with!stressful!situations,!and!exhibit!self`destructive!behavior.688,689!Effective!interventions!to!alleviate!abuse!risk! factors! and!mitigate! negative! outcomes! should! therefore! be! a! priority! for! child! protection! actors!and!a!key!component!of!inter`sectoral!planning.!!Victims! of! sexual! and! gender`based! violence! require! timely! access! to! justice,! legal,! medical! and!psychosocial! services.! Even! prior! to! the! earthquake,! however,! the! Haitian! Government! lacked! the!capacity! to! effectively! prevent! and! respond! to! SGBV.! Thus,! victims! have! historically! lacked! access! to!medical!and!psychosocial!services!and!have!been!unable!to!receive!necessary!interventions.690!Access!is!also! limited!by! social! stigma! surrounding!SGBV!victims,!even! though!a! large!proportion!of! the! female!population!has!experienced!abuse.691!Responding!to!SGBV!requires!a!continuum!of!care.!Even!following!the! rapid! post`earthquake! influx! of!medical! response! organizations,!which!were! capable! of! providing!services!for!the!clinical!management!of!cases,!few!post`clinical!referral!options!were!available.!After!the!earthquake,!moreover,!there!were!few!mental!and!psychosocial!support!operations,!and!the!shortage!of!legal!support!further!limited!victims’!access!to!justice!mechanisms.!Organizations!such!as!Kay!Fanm!and!SOFA!that!were!providing!services!to!victims!before!the!earthquake!have!been!overwhelmed,!and!lack!of! funding! and! capacity! constraints! limit! their! ability! to! respond! to! the! magnitude! of! the! post`earthquake!need.692!!In! addition,! access! to! and! utilization! of! existing! services! remains! extremely! low! in! Haiti.! In! 2002,! the!World!Bank!found!that!66%!of!SGBV!victims!never!reported!their!attacks!to!the!authorities,!even!though!79%! of! victims! could! identify! the! perpetrator.693! This! finding!was! concordant!with! a! range! of! studies!showing! that! the! vast! majority! of! cases! are! not! reported,! thus! complicating! efforts! to! combat!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!685!M.!J.!Small,!J.!Gupta,!R.!Frederic,!et!al.,!“Intimate!partner!and!nonpartner!violence!against!pregnant!women!in!rural!Haiti,”!International&Journal&of&Gynecology&and&Obstetrics!102!(2008),!pp.!226`231.!









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perpetrator! impunity,! deliver! justice,! and! gain! restitution.694,695! As! noted! earlier,! available! evidence!suggests! that! the! incidence! of! sexual! and! gender`based! violence! has! increased! since! the! 2010!earthquake.!Some!sources!suggest!that!this!may!be!due,!in!part,!to!increased!reporting!of!SGBV!cases,!given! the! improved! availability! of! reporting! systems! and! a! rise! in! public! education! campaigns! urging!victims!to!come!forward.696!However,!despite!the!influx!of!medical!services!to!Haiti!in!2010,!most!victims!did!not!seek!out!care!because!they!were!unaware!that!services!were!free,!they!were!unable!to!pay!for!transportation! to! treatment! centers,! and/or! because! they! feared! retaliation.697! Many! victims! have!remained!unwilling!or!unable!to!report!crimes!because!perpetrators!live!in!the!same!camp!or!in!nearby!areas.!Victims!regard!reporting!violations!to!police!and!other!authorities!as!futile,!due!to!lack!of!police!follow`up!and!the!de&facto!requirement!that!victims!identify!the!perpetrator.698,699!!In!the!past!seven!years,!two!landmark!reforms!were!adopted!in!response!to!international!concern!over!the! inadequacy! of! sexual! violence! legislation.700,701! A! Presidential! Decree! was! issued! in! 2005! that!reclassified!rape!as!a!criminal,!rather!than!a!moral,!offense.702,703!As!a!result,!the!maximum!punishment!for!rape!increased!from!two!years!to!15!years!of!forced!labor,!with!the!possibility!of!life!if!the!victim!is!younger!than!16.704!Further,!Haiti!ratified!ILO!Convention!182!on!the!worst!forms!of!child!labor,!and!in!












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2007! the! Ministry! of! Social! Affairs! introduced! the! National! Plan! for! the! Protection! of! Vulnerable!Children.705!!Child! protection! advocates! assert! that! the! full! implementation! of! the!National! Plan! and!provisions! of!Convention!182!would!significantly!contribute!to!addressing!SGBV! in!Haiti.!However,!State! institutions!charged! with! the! implementation! of! these! reforms,! including! those! in! the! justice! sector,! were,! and!remain,! insufficiently! supported! to!meet! policy! objectives.706,707! As! of!March! 2010,! operational! police!stations!lacked!facilities!allowing!victims!to!report!abuses!safely!and!confidentially.708!Despite!the!2005!Presidential!Decree,!which!reclassified!rape!as!a!criminal!offence,!very!few!trials!for!rape!offenders!had!taken!place!as!of!2008,!and!prosecution!rates! for!sexual!violence!remained!extremely! low,!reinforcing!women’s!reticence!to!report!violations.709!In!its!2010!Post`Disaster!Action!Plan,!the!Haitian!Government!recognized!the!importance!of!implementing!measures!to!prevent,!support!the!victims!of,!and!punish!the!perpetrators! of! SGBV,710! although! it! remains! unclear! whether! this! commitment! will! be! backed! by!requisite!investment!and!implementation.!!The!absence!of!reliable!and!comprehensive!estimates!regarding!the!current!extent!of!SGBV!risk!factors!and!outcomes!amongst!Haiti’s!children!inhibits!efforts!to!respond!effectively!to!the!needs!of!victims!and!stymies! the! success! of! post`earthquake! recovery! strategies! implemented! by! state! and! non`state!actors.711,712,713,714,715,716! In! 2008,! Amnesty! International! noted! that! no! unified! mechanism! existed! for!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!705!Amnesty!International,!Overcoming&poverty&and&abuse:&Protecting&girls&in&domestic&service&in&Haiti!(November!2009).!Available!at!http://www.amnesty.org/en/library/info/AMR36/004/2009!!








713!OMCT,!Rights&of&the&child&in&Haiti!(October!2002).!Available!at!http://www.omct.org/files/2001/11/1155/haitichildren2002.pdf!!


!


collecting!and!analyzing!information!on!SGBV!in!Haiti.!As!a!result,!analyses!are!generally!conducted!on!the! basis! of!ad& hoc! reports! by!NGO! service! providers.717! In! light! of! this! shortcoming! and!with! a! view!towards!creating!better!SGBV!policy!and!programming!in!Haiti,!the!UN!Committee!on!the!Rights!of!the!Child! recommended! that! the! Haitian! government! establish! mechanisms! for! the! comprehensive!collection!and!analysis!of!information!relating!to!SGBV.718!At!the!time!of!writing,!the!continuing!absence!of! these! mechanisms! hampers! the! ability! of! the! Haitian! Government! and! other! responders! to!implement!evidence`based!strategies!to!prevent,!respond!to,!and!punish!perpetrators!of!SGBV.!!!

D.&Children&without&parental&care&!This! section! and! the! one! that! follows! will! consider! the! situation! of! children! who! are! separated,!unaccompanied,! orphaned,! and/or! living! in! single`parent! households,! as! well! as! the! risks! faced! and!coping!strategies!employed!by!these!children!both!before!and!after!the!January!2010!earthquake.!The!response! activities! implemented! by! domestic! and! international! actors! also! will! be! examined! in! this!section.!!!Children! without! parental! care! are! among! the! most! vulnerable! in! society! due! to! the! absence! of!alternative! coping! strategies! and! social! support! networks! that! provide! an! adequate! substitute! for!familial!care.!Article!29(a)!of!UN!General!Assembly!Resolution!64/142!(February!2010)!defines!children!without! parental! care! as! “all! children! not! in! the! overnight! care! of! at! least! one! of! their! parents,! for!whatever! reason! and! under!whatever! circumstances,”719! which! is! intended! to! exclude! those! children!living!with!one!parent.!However,!this!Report!will!use!the!term!as!it!is!often!operationally!interpreted!by!UNICEF!and!others!as!children!not!living!with!both!parents,!as!can!be!the!case!with!orphans,!rather!than!those!not!living!with!either!parent.720!!!Several!subcategories!of!children!without!parental!care!can!be!differentiated:!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!715!K.!Tong!and!F.!Gaillardin,!Adolescent&sexual&and&reproductive&health&assessment&mission&to&PLAN,&Haiti!(July!2010).!




719!Guidelines!for!the!Alternative!Care!of!Children,!G.!A.!Res.!64/142!(2010).!Available!at!http://www.unicef.org/protection/alternative_care_Guidelines`English.pdf!!

720!UNICEF,!Child&Protection&Information&Sheet:&Children&without&parental&care!(May!2006).!Available!at!http://www.unicef.org/chinese/protection/files/Parental_Care.pdf!

&



• Children&in&single5parent&households:&children!in!a!household!in!which!one!legal!parent!cares!for!them!without!the!assistance!of!another!legal!parent.!

• Orphan&children:&children!for!whom!at!least!one!parent!is!known!to!be!deceased.721!• Separated& children:! children! separated! from! both! parents,! or! from! their! previous! legal! or!

customary! primary! caregiver,! but! not! necessarily! from! other! relatives.! These!may,! therefore,!include!children!accompanied!by!other!adult!family!members.722!

• Unaccompanied& children:& children! who! have! been! separated! from! both! parents! and! other!relatives!and!are!not!being!cared!for!by!an!adult!who,!by!law!or!custom,!is!responsible!for!doing!so.723!

!UNICEF! categorizes! children! of! each! group! as! “vulnerable! children”.724,725! It! is! important! to! note! that!these! categories! are! not! mutually! exclusive,! as! orphan! children! may! be! living! in! a! single`parent!household,! or!may! be! separated! or! unaccompanied.! Additionally,! all! unaccompanied! children! are,! by!definition,!separated!children.!!The!EMMUS!II,! III,!and!IV!surveys,!conducted!in!1994/95,!2000,!and!2005/06,!respectively,!provide!the!most!comprehensive!estimates!of!orphans!and!resident!parents!in!households!that!include!children.!In!the!1994/95!EMMUS!II!study,!it!was!estimated!that!11%!of!children!under!age!15!were!orphans,!having!lost!one!or!both!parents.726!In!1995,!the!U.S.!Census!Bureau!estimated!a!higher!proportion,!stating!that!15.5%!of! all!Haitian! children!under! age!15!had! lost! at! least! one!parent,!with! 9.3%! lacking! a! surviving!father,! and! 6.2%! having! lost! either! their! mother! only! or! both! parents.727! However,! only! half! of! all!children!under!age!15!were!living!in!a!household!with!both!biological!parents!at!the!time!of!the!EMMUS!II!survey.!This!indicated!that!a!significant!proportion!of!those!whose!mothers!and!fathers!were!still!alive!were! also! living! in! a! household! with! only! one! or! neither! of! their! parents.728! Of! children! living! with!neither! or! only! one! parent,! the! EMMUS! II! survey! found! that! 82%! had! two! surviving! parents.729! As! a!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!721!UNICEF,!Orphans!(February!2009).!Available!at!http://www.unicef.org/media/media_45279.html!!722!ICRC,!Inter5agency&guiding&principles&on&unaccompanied&and&separated&children!(January!2004).!Available!at!http://www.ecdgroup.com/docs/lib_004784237.pdf!!

723!ICRC,!Inter5agency&guiding&principles&on&unaccompanied&and&separated&children!(January!2004).!Available!at!http://www.ecdgroup.com/docs/lib_004784237.pdf!!


survey!(2006).!Available!at!http://www.measuredhs.com/pubs/pub_details.cfm?id=767&srchTp=home!725!ICRC,!Inter5agency&guiding&principles&on&unaccompanied&and&separated&children!(January!2004).!Available!at!http://www.ecdgroup.com/docs/lib_004784237.pdf!!



727!Family!Health!International!(FHI),!The&situation&of&orphans&in&Haiti:&A&summary&assessment:&A&preliminary&

assessment&of&orphans&and&vulnerable&children&with&a&focus&on&children&affected&by&HIV/AIDS!(2001).!Available!at!http://dspace.cigilibrary.org/jspui/handle/123456789/8649?mode=full!!





!


result,!it!can!be!inferred!that,!a!significant!proportion!of!children!who!were!not!orphans!were!separated!and!unaccompanied.!!The!EMMUS!III!survey!in!2000!found!a!similar!proportion!of!children!living!without!both!parents!in!the!household.!Haiti`wide,! it!was! found!that!51%!of!children!under!age!15!did!not! live!with!both!parents,!and!that!17%!lived!with!neither!parent,!with!the!remaining!32%!living!in!a!single`parent!household.!The!proportion!of!children!not!living!with!both!parents!was!higher!in!Port`au`Prince,!where!61%!of!children!were! living!with!only!one!or!neither!parent.!Of! children! in! the!metropolitan!area,! approximately!35%!lived!only!with!their!mother,!8%!only!with!their!father,!and!17%!with!neither!parent!(Figure!54).730!The!U.S.! Census! Bureau! estimated! that,! countrywide,! 13.2%! of! all! children! had! lost! one! or! both! parents,!7.3%!having!lost!their!father,!and!5.9%!having!lost!either!their!mother!only!or!both!parents.731!It!should!be!noted! that! this!proportion! is! lower! than!estimates! for!1995,!perhaps!due! to! the!aging!of! the!1995!child!cohort!coupled!with!a!decrease!in!civic!violence!and!a!concomitant!decrease!in!parental!death!for!the!2000!child!cohort!in.!!Figure.54:.Parental.residence.in.household,.Haiti.and.PortTauTPrince.metropolitan.area,.2000.

Living.with.one.or.neither.parent.

Living.with.mother.

Living.with.father.

Living.with.neither.parent.

Haiti. Metropolitan.area.

Metropolitan.area.

Metropolitan.area. Haiti. Metropolitan.

area.51%! 61%! 35%! 8%! 17%! 17%!

Data!source:!World!Bank,!Social&resilience&and&state&fragility&in&Haiti:&A&country&social&analysis,!Caribbean!Country!Management!Unit,!Report!no.!36069`HT!(April!2006).!Available!at!http://siteresources.worldbank.org/SOCIALANALYSIS/1104894`1115795935771/20938696/Haiti_CSA.pdf!!

!!By! 2006,! the! proportion! of! children! living!with! both! parents! had! fallen! again.! The! EMMUS! IV! survey!found! that! 60%! of! Haitian! children! aged! 10`14! did! not! live! in! a! household! with! both! parents,732,733!although! this! proportion!was! slightly! lower! (55%)! for! all! children! under! age! 18.734! The! proportion! of!children! living! with! both! parents! was! higher! in! rural! areas! (47%)! than! in! urban! areas! (28%).!Approximately!27%!of!all!Haitian!children!lived!only!with!their!mother!in!2006,!with!a!slight!difference!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!730!World!Bank,!Social&resilience&and&state&fragility&in&Haiti:&A&country&social&analysis,!Caribbean!Country!Management!Unit,!Report!no.!36069`HT!(April!2006).!Available!at!http://siteresources.worldbank.org/SOCIALANALYSIS/1104894`1115795935771/20938696/Haiti_CSA.pdf!







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between!urban!(31%)!and!rural!(25%)!areas.!Conversely,!7%!of!all!children!in!Haiti!lived!with!only!their!father,!with!a!slightly!higher!proportion!in!rural!areas!(7.5%)!compared!to!urban!areas!(6.8%).!Country`wide,! roughly! 25%!of!Haitian! children! lived!with! neither! parent! in! 2006,!with! children! in! urban! areas!experiencing! a! higher! likelihood! of! living! with! neither! parent! (34%)! than! their! rural! counterparts!(20%).735,736!

!In! addition! to! disparities! according! to! urban/rural! status,! the! EMMUS! IV! survey! found! significant!differences!in!the!probability!of!living!with!both,!either,!or!neither!parent/s!on!the!basis!of!child!gender!(Figure!55!and!Figure!56).!In!urban!areas,!boys!aged!10`14!were!almost!50%!more!likely!to!be!living!with!both!parents!and!27%!more!likely!to!be!living!with!only!their!mother!than!urban!girls,!while!they!were!only! 61%!as! likely! to! be! living!with! neither! parent.! In! rural! areas,! differences! according! to! the! child’s!gender!were!not!as!significant,!but!boys!remained!less!likely!to!be!living!with!neither!parent!than!girls.737!!






!


Figure.55:.Parental.residence.in.household,.by.region,.urban/rural.status,.and.child's.gender,.2006.



!!A!number!of! studies!have! found! that,! in!Haiti,! the! gender!of! a! single!head!of!household!affects! their!children’s!enjoyment!of! rights.! In!2001,! Family!Health! International! found! that!households!headed!by!women!tended!to!be!poorer!than!those!headed!by!men.738!This!finding!was!supported!by!a!subsequent!World! Bank! analysis,! using! data! from! a! 2001! survey,!which! found! that! female`headed! households! in!rural!Haiti!were!11%!more! likely! to!be!deemed! “poor”! than! those!headed!by!men.739! The!Population!Council! suggested! that! lower! incomes,! lack! of! social! power,! and! a! dearth! of! protections! afforded! to!single!mothers! in!Haitian!society!might!contribute!to!greater!risks!for!their!children.740!However,!while!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!738!Family!Health!International!(FHI),!The&situation&of&orphans&in&Haiti:&A&summary&assessment:&A&preliminary&





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these! analyses! found! indirect! associations! between! female`headed! households! and! children’s!enjoyment! of! their! rights,! a! 1996! study! by! Devin! and! Erickson! showed! that! children! in!male`headed!households!were!more! likely! to! experience! certain! poor! outcome!measures! than! children! in! female`headed!households.!In!particular,!they!found!that!children!in!male`headed!households!were!more!likely!to!be!malnourished!than!children!with!a!female!caregiver.!The!authors!hypothesized!that!this!could!be!a!result! of! the!men’s! relative! lack! of! nutritional! awareness,! as!well! as! a! higher! propensity! to! leave! the!house! and! any! young! children! therein! in! the! care! of! older! siblings.! In! the! absence! of! grandmothers,!older! daughters,! or! other! female! relatives! who! could! care! for! younger! children,!men!were! generally!perceived!as!the!caregivers!of!last!resort,!as!children!in!male`headed!households!were!thought!to!be!at!greater!risk.741!!Figure.56:.Parental.residence.in.household,.by.urban/rural.status,.and.child's.gender,.2006.



!!Fewer!data!exist!on!the!prevalence!of!orphan!children!in!Haiti!than!on!the!status!of!parental!residence!with! children.! The! EMMUS! IV! survey! again! provided! the! most! robust! estimate! of! the! proportion! of!children!who!experienced!the!death!of!one!or!both!parents!prior!to!the!2010!earthquake.!In!2005`6,!the!survey! estimated! that! 11%! of! all! Haitian! children! had! lost! at! least! one! parent,! and! that! 1.3%! of! all!Haitian! children!had!no! surviving!parents.742,743,744!A! larger!proportion!of!urban!children!were!orphans!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!741!R.!B.!Devin!and!P.!I!Erickson,!“The!influence!of!male!care!givers!on!child!health!in!rural!Haiti,”!Social&Science&&&Medicine!43/4!(1996),!pp.!479`488.!


survey!(2006).!Available!at!http://www.measuredhs.com/pubs/pub_details.cfm?id=767&srchTp=home!743!PAHO,!Health&in&the&Americas&2007:&Volume&II&–&countries:&Haiti!(2007).!Available!at!http://www.paho.org/hia/archivosvol2/paisesing/Haiti%20English.pdf!!

!


(13%)!than!rural!children!(10%),!potentially!as!a!result!of!urban`focused!civil!unrest!prior!to!the!survey!period.745!Small!differences!were!observed!according!to!the!child’s!gender!(Figure!57).746!!Figure.57:.Parental.survival.among.children.aged.10T14,.by.gender.and.urban/rural.status,.2006.



!!The!January!2010!earthquake!undoubtedly!had!a!profound!impact!on!the!proportion!and!composition!of!children! without! parental! care! in! Haiti.! As! there! have! been! no! nationally! representative! surveys!assessing!children’s! living!situation!since! the!earthquake,!deriving!estimates! that!are!methodologically!comparable!to!the!set!of!EMMUS!surveys!is!impossible.!However,!the!perspective!is!widely!shared!that!the! proportion! of! children! living! in! households! with! only! one! or! neither! parent! has! increased,747!especially!given!that!one!in!five!families!in!earthquake`affected!areas!experienced!the!death!of!at!least!one! family!member.748! This!perspective! is! in! keeping!with! findings!made! in!other! contexts! that! large`

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!744!UN!DESA,!The&millennium&development&goals&report&2009!(New!York,!July!2009).!Available!at!http://www.un.org/en/development/desa/news/statistics/mdg`2009.shtml!!


survey!(2006).!Available!at!http://www.measuredhs.com/pubs/pub_details.cfm?id=767&srchTp=home!746!Population!Council/UNFPA,!The&adolescent&experience&in5depth:&Using&data&to&identify&and&reach&the&most&




&



scale! disasters! often! lead! to! family! separation,! as! family! members! cannot! as! easily! trace! and!communicate!with!one!another.!After!the!earthquake!many!children!were!sent!to!live!with!friends!and!family! members! outside! of! earthquake`affected! areas.749,750,751! Additionally,! the! practices! of! sending!children! to! become! domestic! servants! and! of! placing! children! in! orphanages! as! a! response! to!poverty,!rather!than!parental!death,!was!likely!to!have!intensified!following!the!earthquake!due!to!the!suspension! of! economic! opportunities! and! the! dissolution! of! prior! livelihood! strategies.752! These! two!motivations! are! discussed! further! in! Sections!9A.& Children& in& domestic& service& and& servitude! and!5D.i.&Orphanages&and&other&private&institutions,!respectively.!!Due!to!the!progressive!registration!of!additional!separated!and!unaccompanied!children;!the!continuing!flow!of!children!between!family!members,!friends,!and!institutions;!the!confidentiality!of!the!UN!Child!Protection!Sub`Cluster!database!of! registered!separated!and!unaccompanied!minors;!and!the!absence!of!a!nationally!representative!survey!enumerating!vulnerable!children,!estimates!of!the!total!number!of!children!without!parental!care!vary!by!time!periods,!sources,!and!assessment!areas.! In!February!2010,!the! U.S.! Centers! for! Disease! Control! and! Prevention! stated! that! 27`49%! of! sites! surveyed! by! the! UN!Initial!Rapid!Assessment! reported! the!presence!of!unaccompanied! children.753! In!March!2010,! a! rapid!assessment!conducted!by!World!Vision!across!60!sites! in!Port`au`Prince!and!four!of!the!organization’s!operational!regions!found!that!community!leaders!reported!approximately!2,280!separated!children!in!21! communities.! Of! those! children,! 168! were! identified! across! six! communities! in! La! Gonâve,! 1,678!across!seven!communities!in!Sud!Department,!134!across!six!communities!and!camps!in!Plateau!Central,!and!more!than!300!across!two!communities!in!the!Nord!Department.!Household!interviews!yielded!an!estimate!of!1,545!children!separated! from!their! families! in!20!surveyed!camps!and!communities.754! In!March!2010,! the!Haitian!Government!stated!that!103,000!cases!of!children!without!parental!care!had!been! identified! nationwide,755,756! while! by! July! 2011,! UNCEF! stated! that! 8,212! separated! and!unaccompanied!children!had!been! registered.757! It! is!unclear!what!proportions!of! these!children!were!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!749!World!Vision,!Rapid&assessment&report:&Haiti&earthquake&response!(March!2010).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/Full_Report_583.pdf!!


751!ICRC,!Inter5agency&guiding&principles&on&unaccompanied&and&separated&children!(January!2004).!Available!at!http://www.ecdgroup.com/docs/lib_004784237.pdf!!


753!CDC,!CDC&summary&of&initial&rapid&assessment&conducted&by&UN&OCHA&in&Haiti!(February!2010).!754!World!Vision,!Rapid&assessment&report:&Haiti&earthquake&response!(March!2010).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/Full_Report_583.pdf!!




!


considered! separated! and! unaccompanied!minors,! orphans,! children! in! or! of! the! street,! or! living! in! a!single`parent! household;! neither! is! it! evident! how! these! children! were! distributed! across! Haiti.! As! a!matter!of!urgency,!the!U.S.!Centers!for!Disease!Control!and!Prevention!has!stated!that!further!research!and!intervention!should!be!conducted!to!remedy!the!inadequacy!of!currently!available!information!on!children!without!parental!care.758!!Following!the!earthquake,!available!evidence!suggested!that!familial!and!friendship!networks!played!a!significant! role! in! responding! to! the!needs!of!many!children!without!parental! care.!Numerous! reports!cite!the!placement!of!vulnerable!children!with!extended!family!and!friends!outside!earthquake`affected!areas.759,760,761!These!placements!are!not!a!new!phenomenon,!having!commonly!been!used!as!a!strategy!to!spread!risk!and!meet!children’s!needs!even!prior!to!the!earthquake.762,763!At!the!time!of!the!1994/95!EMMUS!II!survey,!28%!of!urban!and!24%!of!rural!households!were!caring!for!foster!children,!with!most!of!those!children!constituting!part!of!the!household’s!extended!family.764!Many!children!not!placed!with!family!or!friends!were!sent!to!orphanages!in!the!hope!that!these!institutions!would!better!provide!for!the! child! than! did! their! former! household! (discussed! further! in! Section! 5D.i.& Orphanages& and& other&private& institutions).765,766,767,768! Many! children! today! also! live! without! parental! care! in! IDP! camps!established! following! the! 2010! earthquake.!World! Vision’s!March! 2010! rapid! assessment! found! that!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!758!CDC,!CDC&summary&of&initial&rapid&assessment&conducted&by&UN&OCHA&in&Haiti!(February!2010).!759!UNICEF,!Children&of&Haiti:&Milestones&and&looking&forward&at&six&months!(July!2010).!Available!at!http://www.unicef.org/emerg/files/UNICEF_Haiti_`_Six_Months_Report_Final.pdf!!




763!S.!C.!Wortham,!“The!young!child!and!social!relationships!in!developing!countries,”!in:!M.!R.!Jalongo!(ed),!Enduring&bonds:&the&significance&of&interpersonal&relationships&in&young&children’s&lives!(Indiana:!Springer,!2007).!




767!M.!Loudon,!A&study&of&integrated&interventions&for&children&made&vulnerable&by&HIV/AIDS&in&Haiti:&A&case&study&




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separated! and! unaccompanied! children’s! residences! in! camps! were! especially! prevalent! in! Plateau!Central,!compared!to!La!Gonâve!and!Nord!and!Sud!Departments.769!!In!general,!children!without!parental!care!face!greater!risk!of!discrimination,!physical!and!sexual!abuse,!exploitation,! lack! of! representation,! and! impaired! emotional! and! social! development.770! Children!without! parental! care! in! Haiti! face! heightened! risk! of! domestic! servitude,771! trafficking,772,773!

abandonment,774! involvement! with! gang! activity! and! urban! violence,775! and! forced! prostitution.776!Smucker!et&al.!note!that!children!in!orphanages!may!be!vulnerable!to!sexual!abuse!by!staff.777!In!many!cases,!these!risks!were!present!before!the!2010!earthquake.!However,!the!magnitude!and!prevalence!of!threats! to! the! protection!of! children!without! parental! care! has! been! exacerbated!by! the! earthquake,!leaving! many! without! access! to! requisite! basic! services! or! support! systems.778,779! Additionally,! those!living! in!temporary!camps!or!precarious!dwellings!face! increased!vulnerability!from!flooding!and!other!environmentally! related! events.! This! further! increases! the! likelihood! of! secondary! displacement,!morbidity,!and!mortality!among!these!children.780! In!order!to!effectively!mitigate!these!risks,!response!and!reconstruction!efforts!must!be!buttressed!by!information!that!both!facilitates!the!effective!targeting!of!children!most!at!risk!and!enables!appropriate!assessment!of!the!impacts!of!these!risks!on!children’s!realization!of!their!rights.!!













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The! domestic! and! international! response! to! the! needs! of! Haitian! children! without! parental! care! has!been!subject!to!a!range!of!challenges,!including!a!lack!of!comprehensive!disaggregated!assessments,!the!inherently! hidden! nature! of! the! phenomenon,! lack! of! access,! and! the! devastation! massed! by! the!earthquake!on! already! insufficient! human! resources,! logistical! capacity,! and!physical! infrastructure.781!Prior! to! the! earthquake,! only! 5%! of! households! hosting! orphans! and! other! vulnerable! children!were!receiving! at! least! one! form! of! external! support.782! Two! flagship! initiatives! introduced! since! the!earthquake! have! attempted! to! respond! to! the! needs! of! these! children.! In! the!months! following! the!disaster,! UNICEF! directed! the! establishment! of! a! call! center! for! frontline! relief! workers! to! register!children! identified!as! separated!and!unaccompanied!minors.783! The! situation!of! these! children! is! then!evaluated! by! an! organization! responsible! for! the! child’s! geographical! region,! and! their! information! is!added! to! a! secure! database! that! is! used! to! trace! families.! By! July! 2011,! 8,212! separated! and!unaccompanied!children!had!been!registered.784!In!addition,!the!Haitian!Government!has!identified!as!a!priority! the! establishment! of! transit! centers! for! separated! and! unaccompanied! children! in! each!earthquake`affected! town.! These! transit! centers! help! to! trace! children’s! families! and! provide! basic!services!and!financial!assistance.785!Without!comprehensive!baseline!data,! it! is!unclear!how!effectively!these!initiatives!have!addressed!the!enormity!of!need!created!in!the!wake!of!the!earthquake!for!Haiti’s!children!without!parental!care.!However,!the!successful!reunification!of!more!than!1,265!children!with!their!families!by!January!2011!is!cause!for!hope.!!!

i..Orphanages.and.other.private.institutions.!Despite!prominence!in!international!media!reports!following!the!2010!earthquake,!the!issue!of!Haitian!children!living!in!orphanages!and!other!private!care!facilities!either!before!or!after!the!earthquake!has!received!relatively!little!assessment.!According!to!UNICEF,!approximately!50,000!children!were!living!in!roughly! 600! institutions! across! Haiti! prior! to! the! earthquake.786,787,788! Family! Health! International!



survey!(2006).!Available!at!http://www.measuredhs.com/pubs/pub_details.cfm?id=767&srchTp=home!783!UN!MINUSTAH,!Haiti:&6&months&after…!(July!2010).!Available!at!http://www.un.org/en/peacekeeping/missions/minustah/documents/6_months_after_commemoration.pdf!!





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estimated! that! between! 7`8%! of! all! vulnerable! children!were! housed! in! orphanages! or! other! private!organizations!in!2001,!although!they!also!noted!that!the!true!number!remains!unknown.789!The!capacity!of!the!Haitian!state!to!license,!regulate,!monitor!and!report!on!orphanages!is!extremely!limited,!and!the!absence!of!oversight!and!regulation!of!this!sector!has!made!it!difficult!to!estimate!precisely!the!number!of!children!living!in!orphanages,!as!well!as!the!number!of!orphanages,!themselves.!The!result!is!a!dearth!of! information! regarding! the! sector! and! the! need! for! further! enquiry! regarding! both! the! number! of!children!living!in!orphanages!in!Haiti!and!their!living!situations!within!these!care!facilities.!!The!government!department!responsible!for!the!oversight!of!this!sector,!the!Institute!for!Social!Welfare!and!Research!(Institut&du&Bien5être&Social&et&de&la&Recherché,&or!IBESR),!suffers!from!severely!constrained!human! and! financial! resources.! As! a! result,! few! orphanages! are! registered,! and! a! smaller! proportion!monitored,! ensuring! that! children’s! experiences! in! orphanages! are! a! largely! hidden! phenomena.790!Officially,! private! orphanages! are! required! to! receive! a! license! from! IBESR! before! commencing!operations.!In!reality,!however,!the!proliferation!of!private!institutions!run!by!charitable!organizations,!operate!completely!outside!of!the!sphere!of!government!oversight.!IBESR!also!lacks!sufficient!absorptive!capacity!for!the!number!of!children!entrusted!to!its!care,!and!thus!refers!temporary!placement!of!these!children! to! private! facilities! until! they! can! be! returned! to! their! families! or! permanent! placement!arranged.791,792!!!Socioeconomic!and!livelihood!factors!play!a!significant!role!in!the!decision!to!place!a!child!in!institutional!care,!where!parents!often!believe!their!child!will!benefit!from!greater!access!to!education,!healthcare,!and!other!basic!needs.793,794,795,796!The!vast!majority!of!children!living!in!Haitian!orphanages!are!not!true!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!788!UN!OCHA!Haiti,!Haiti&before&January&12th,!Internal!document!(2010).!Available!at!http://ochaonline.un.org/OchaLinkClick.aspx?link=ocha&docId=1165439!!












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orphans,! in! the! sense! that! they! have! lost! one! or! both! of! their! parents.797!Many! children! are! instead!placed!in!orphanages!in!what!is!seen!as!a!temporary!arrangement.!Often,!parents!continue!to!visit!these!children,!with!plans!to!remove!them!from!the!orphanage!once!the!family’s!situation!improves.!As!such,!these! facilities! are! viewed! in! a! manner! consistent! with! an! informal! and! time`limited! fosterage!arrangement,! underscoring! the! temporary! and! financial! motivation! for! their! children’s!placement.798,799,800,801!!!Children’s! placement! in! orphanages! carries! significant! developmental! risks,! which! must! be! weighed!against!expected!benefits!before!determining!whether!institutionalization!is!in!the!true!best!interests!of!the! child.! These! risks! include! sexual! assault,! which! Smucker& et& al.! found! to! be! significantly! more!common! among! children! in!Haitian! orphanages! than! those! living!with! their! families.802! Tolfree! neatly!summarizes!the!risks!faced!by!children!in!institutionalized!care!in!Haiti!as:!!

…! the!segregation,!discrimination!and! isolation! that! institutionalised!children!often!experience;!the!fact!that!admission!is!often!based!on!the!needs!of!parents,!not!the!interests!of!children;!the!lack!of!personal!care!and!stimulation;!the!lack!of!opportunities!to!learn!about!the!roles!of!adults;!the! high! risk! of! institutional! abuse;! the! lack! of! attention! to! specific! psychological! needs;! and!finally,! reflecting! all! of! these! features,! the! fact! that! institutionalised! children! often! experience!problems!in!adjusting!to!life!outside!of!the!institution.803!

!Several! promising! initiatives! were! undertaken! in! the! decade! before! the! earthquake! to! improve! the!quality! of! care! for! children! living! in! orphanages.! At! the! national! level,! the! Chambre! de! l’Enfance!Nécessiteuse!Haïtienne!(CENH)!was!established!to!register!orphanages!and!improve!the!quality!of!their!operation! through! management! training! and! accountability! mechanisms.! Supported! by! USAID,!orphanage! registration! was! conditional! upon! the! satisfaction! of! established! criteria.804! While! this!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!797!UNICEF,!Progress&for&children&number&8:&A&report&card&on&child&protection!(September!2009).!Available!at!http://www.unicef.org/protection/files/Progress_for_Children`No.8_EN_081309(1).pdf!!








803!Cited!in:!M.!Loudon,!A&study&of&integrated&interventions&for&children&made&vulnerable&by&HIV/AIDS&in&Haiti:&A&

case&study&of&La&Maison&l’Arc5en5Ciel,!UNAIDS/UNICEF!(2006).!Available!at!http://www.unicef.org/lac/Haiti_Case_Study`Children_made_Vulnerable_by_AIDS(1).pdf!!



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initiative!is!a!positive!step!towards!improving!the!lives!of!children!in!orphanages,!the!extent!of!its!impact!remains!unclear.!As!only!those!orphanages!meeting!the!established!criteria!are!registered,!it!can!be!said!that!management!training!and!accountability!mechanisms!were!only!established!for!those!orphanages!least! in!need;!meanwhile,!orphanages!that!did!not!meet!the!criteria!remained!hidden!due!to!a! lack!of!registration,!and!were!of!lower!quality!and!capacity!due!to!the!absence!of!training.!!Also!of! note! are! two!orphanages! that!have!provided!a!model! for! integrated!HIV/AIDS!orphan! care! in!Haiti.!Maison! L'Arcèn`Ciel,! in!Portàu`Prince,!provides!a! family`! and!community`based! system!of! care!for! HIV/AIDS! orphans,! and! provides! support! to! HIVàffected! families! in! surrounding! communities!through!counseling,! training,!and! food!aid.805! Similarly,!CHOAIDS!employs!HIV`positive!women! to!care!for! children! orphaned! by! HIV/AIDS! and! establish! a! family! support! environment.! Anecdotal! evidence!suggests! that! this! “mother”`child! relationship! benefits! both! parties,! as! the! children! are! reared! in! an!individualized,!supportive!atmosphere,!while!the!women!feel!trusted!and!empowered!as!caregivers!and!decision`makers.806!!Since! the! January! 2010! earthquake,! little! public! information! has! become! available! regarding! the!situation!of!children!living!in!Haitian!orphanages!and!other!private!care!institutions.!Children!from!many!orphanages! were! removed! from! Haiti! following! the! earthquake,! many! with! surviving! relatives,! as!governments! and! international! organizations! rushed! to! safeguard! children! from! potential! harm! (See!Section!4C.&Adoption).!By!July!2010,!the!United!Nations!had!recruited!forty!social!workers!to!investigate!orphanages!and!other!childcare!institutions!in!earthquakeàffected!areas,807!while!International!Medical!Corps!planned!to!conduct!an!evaluation!of!200!orphanages!before!December!2010.!The!results!of!these!assessments!were!unavailable!at!the!time!of!this!writing.!!!!

E.&Children&in&and&of&the&street&!For! analytical! and! programming! purposes,! it! is! necessary! to! differentiate! between! “children! in! the!street”! and! “children! of! the! street.”! Children! in! the! street! are! generally! considered! to! be! those!who!spend! some! or! all! of! their! time! living! and! sleeping! in! the! street,! but! do! have! families! or! households!where! they! spend!at! least! some!nights.! In! contrast,! children!of! the! street! are! those!who! spend!all! of!their! time! living! and! sleeping! in! the! street,! either! because! they! have! no! known! living! relatives! with!whom! to! stay,! because! they! choose! to! live! and! sleep! in! the! street,! and/or! because! their! current!situation! precludes! them! from! staying! with! their! families! or! in! other! households.! Several! studies!conducted! in! Haiti! have! noted! that! many! “street! children”! have! surviving! family! members! in! their!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!805!Family!Health!International!(FHI),!The&situation&of&orphans&in&Haiti:&A&summary&assessment:&A&preliminary&


806!N.!Romera`Daza,!A.!Ruth,!and!M.!Denis`Luque,!“An!alternative!model!for!the!provision!of!Sservices!to!HIV`positive!orphans!in!Haiti,”!Journal&of&the&Health&Care&for&the&Poor&and&Underserved!20/4!(2009),!pp.!36`40.!


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current! area! of! residence! or! their! area! of! emigration.808,809,810! Some! of! these! children!may! be! better!described!as! children! in! the! street,! as! they!may!visit! and! stay!with! relatives,!often!bringing!money!or!gifts! home!with! them.811,812! As! such,!while! their! link!with! their! families!may! be!weak,! children! in! the!street! have! occasional! access! to! a! residence! where! they! may! sleep,! rather! than! lacking! any! type! of!residence!whatsoever.813!!Notably! in! Haiti,! many! street! children! define! themselves! as! “timoun& lari”! (children! of! the! street)! in!apposition!to!“timoun&lekol”!(children!in!school),!rather!than!“timoun&lakay”!(children!in!homes),!as!the!applicability!of! the! latter! is!negated!by! the! fact! that!many! street! children!have! surviving! families! that!they! occasionally! stay! with.814! Another! effect! of! this! choice! of! definitional! contrast! is! that! stigma!surrounding! living! in! the!streets! is! lower! in!rural!areas,!where! fewer!children!attend!school! in!general!than!in!urban!areas.815!Rather!than!where!they!live!and!work,!the!contrast!these!children!use!to!identify!themselves! also! suggests! that! lack! of! education! (with! education! being! a! highly! prized! characteristic,!discussed! further! in! Chapter! 8.& Education)! may! therefore! be! the! more! important! characteristic!distinguishing!them!from!other!Haitian!children.816!!As! a! group,! children! in! and! of! the! street! are! inherently! difficult! to! quantify,! as! traditional! survey!methods!rely!on!definitions!of!a!household!incorporating!a!permanent!physical!structure,!such!as!a!roof.!Children! in! the! street! are!more! easily! enumerated! than! children!of! the! street,! as! they! spend!at! least!some!of!their!time!living!in!a!household.!However,!the!lack!of!methodologically!rigorous!survey!sampling!strategies!for!street!children!means!that!estimates!are!unreliable,!and!the!true!number!and!prevalences!of!children!in!and!of!the!street!are!likely!to!be!higher!than!those!reported.817!!











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Due!in!part!to!these!methodological!challenges,!the!estimated!number!of!children!in!and!of!the!street!in!Haiti!has!varied!markedly!over! the!past!decade!depending!on!source.! In!1999,!a! survey!by!Quisqueya!University’s! Unit! for! Children! in! Difficult! Situations! estimated! that! there! were! between! 6,226`7,833!children! in! or! of! the! street! aged! 5`17! in! Portàu`Prince,! with! a! further! 163! in! Cap`Haitien! and! 41! in!Jacmel.818!This!estimate!is!roughly!equivalent!to!the!UN!Committee!on!the!Rights!of!the!Child’s!estimate!of!6,400!–!8,000!in!2002.819!By!2004,!however,!Smucker!and!Murray!estimated!significantly!fewer!street!children!in!Portàu`Prince,!with!an!estimate!of!approximately!2,000.820!As!there!were!no!major!initiatives!undertaken! within! this! time! period! to! reduce! the! number! of! street! children,! it! is! probable! that! the!majority!of!variation!between!these!estimates!was! the!result!of! survey!error,! rather! than!a! three`fold!decrease! in! the! true!number!of!children! in!or!of! the!street.!Over! the!period!2004`2009,!most!sources!referenced!UNICEF’s!estimate!of!2,500!street!children!Haiti`wide.821,822,823,824,825!!Smucker!and!Murray!also!noted! that! the!number!of! street! children! in!provincial! towns!had! increased!dramatically!between!1994!and!2004.826!This!finding!was!supported!by!a!followùp!study!in!2009,!which!found!that!a!larger!proportion!of!children!in!troubled!urban!neighborhoods!outside!Portàu`Prince!were!living! in! the! streets! compared! to! those! in! Portàu`Prince! (Figure! 58).827! Although! the! survey’s!methodology!precluded!enumerating!children!of!the!street,!the!finding!suggests!that!the!phenomenon!is! now!prevalent! nationwide,! rather! than! limited! to! Portàu`Prince! and! the! surrounding!metropolitan!areas.! The! authors! suggest! that! greater! access! to! education! in! Portàu`Prince! may! account! for! the!relatively! low!prevalence!of!street!children!compared!to!other!urban!areas!in!Haiti,!where!educational!access!is!more!limited.828!








825!UNICEF!Executive!Board,!Revised&country&programme&document:&Haiti&(200952011)!(2009).!Available!at!http://www.unicef.org/about/execboard/files/Haiti`FRS2009`revised_feb2010Ènglish.pdf!!




!


!Figure.58:.Children.in.the.street.(%).in.troubled.neighborhoods.in.Haiti,.2009.

Site Street children (%) Carrefour Feuilles / Fontamara / Martissant 0 Solino / Bel-Air 1 Cité Soleil 1.8 Delmas / Tabarre 0 Mon Repos / Lamentin 0.7 PORT-AU-PRINCE 0.7 Cap: Bassin Rodo 1.1 Cap: Centre Ville 2.4 Cap: Petite Anse 1.9 CAP HAITIAN 1.8 Gonaïves 2.9 Saint-Marc 6.3 Petit-Goâve 0.9


!!Unfortunately,! estimates! of! the! number! of! children! in! and! of! the! street! following! the! January! 2010!earthquake!are!unavailable.!The!earthquake!undoubtedly!resulted!in!a!massive!increase!in!the!number!of! street! children,! due! to! both! economic! necessity! stemming! from! the! loss! of! an! income`generating!family! member! or! the! destruction! of! pre`earthquake! residences.! Prior! to! January! 2010,! most! street!children! were! migrants! from! the! provinces.! However,! in! the! wake! of! the! earthquake,! a! significantly!higher!proportion!are! likely! to!be!urban!residents!whose!pre`existing!support!strategies!are!no! longer!adequate!to!meet!their!needs.!!!The!literature!identifies!various!causes!for!children!living!in!or!on!the!street.!A!number!of!studies!suggest!that!a! significant!proportion!of! street! children!are!dismissed!or! runaway! child!domestic! servants!who!must!now!make!a! livelihood!without! the!benefit!of!education!or!permanent!home.829,830,831!Poverty! is!identified!as!another!primary!driver!of! the!prevalence!of! street!children.!Due! to! their! families’! lack!of!means,!many! children! are! either! forced! or! volunteer! to! find!work! in! the! streets! to! supplement! their!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!829!U.S.!Department!of!Labor,!Findings&on&the&worst&forms&of&child&labor:&2006&report:&Haiti!(2006).!Available!at!http://www.dol.gov/ilab/map/countries/haiti.htm!



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family’s! income.832,833,834! This! economic! motivation! is! probably! applicable! to! a! greater! proportion! of!children!in!the!street!than!of!the!street,!as!its!primary!reference!point!is!the!socio`economic!situation!of!the!family,!rather!than!of!the!child!alone.!In!contrast,!Kovats`Bernat!states!that!some!children!choose!to!live!in!the!street!because!it!provides!them!with!greater!freedom!and!economic!opportunity!than!staying!at!home.!He!notes!that!performing!odd!jobs,!such!as!washing!cars,!begging,!and!carrying!groceries,!may!allow!the!child!to!earn!twice!the!Haitian!minimum!wage.835!Finally,!some!children!are!forced!to!live!on!the! streets! after! being! deported! from! the! Dominican! Republic,! having! been! separated! from! their!relatives!and!family!and!left!at!the!border!crossing.836!!!Haitian!street!children!are!in!an!extremely!vulnerable!position,!facing!a!multitude!of!risks!to!safety!and!wellbeing.! Foremost! among! these! concerns! are! vulnerability! to! violence! and! adverse! health,! gender`based! violence,! and! lack! of! recourse! to! an! acceptable! juvenile! justice! system,! all! of! which! in! turn!contribute! to!greater! insecurity.! Street! children! face! the! risk!of! violence! from!both! the! justice! system!and!from!other!street!children.!Due!to!their!lack!of!parental!oversight,!moreover,!they!are!often!abused!and! targeted! by! the! police,! and! account! for! a! disproportionately! high! percentage! of! child! prisoners!during! neighborhood! sweeps! by! the! Haitian! National! Police’s! Anti`Gang! Unit.837,838,839,840! Of! the! 57!children!held!at!the!Juvenile!Prison!in!January!2000,!all!but!five!were!previously!living!on!the!streets.841!Street! children! also! face! significant! risks! of! violence! from!other! street! children,! often! related! to! gang!violence.842,843,844,845!Many!street!children!carry!razor!blades!scavenged!from!dumpsters,!and!altercations!between!them!often!lead!to!injury!and,!occasionally,!death.846,847,848!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!832!UN!Committee!on!the!Rights!of!the!Child,!Consideration!of!reports!submitted!by!state!parties!under!article!44!of!the!Convention:!Haiti,!UN!Doc.!CRC/C/51/Add.7!(2002).!Available!at!http://www.unhcr.org/refworld/docid/3df59ad34.html!!








840!J.!Moncrieffe,!“When!labels!stigmatize:!Encounters!with!‘street!children’!and!‘restavecs’!in!Haiti,”!in!J.!Moncrief!and!R.!Eyben!(eds),!The&power&of&labelling:&How&people&are&categorized&and&why&it&matters!(London:!Earthscan,!2007).!



!


!While! living! in! the! street,! children! are! exposed! to! deplorable! sanitary! and! nutritional! conditions! that!underlie!a!wide!range!of!health!problems.!Street!children!are!at!greater!risk!of!acquiring!communicable!diseases!than!other!children,!especially!tuberculosis!and!gastrointestinal!ailments.!They!also!have!little!access! to! safe! drinking! water! or! adequate! nutrition,! suffer! from! headaches,! fatigue,! mental! and!psychosocial! conditions,! skin! diseases,! higher! rates! of! sexually! transmitted! infections,! and! pervasive!drug!use,!especially!sniffing!siment!(cobbler’s!glue).849,850,851,852,853!Young!girls!are!at!higher!risk!of!sexually!transmitted!diseases,! sexual! and!gender`based!violence,! rape,! and!unintended!pregnancy.! These! risks!are! heightened! by! the! fact! that! many! are! forced! into! prostitution! to! survive,! marking! female! street!children!as!an!extremely!vulnerable!population.854,855,856,857!No!quantitative!data!exist,!however,!on!the!prevalence!of!these!health!conditions!and!risk!factors!of!Haitian!street!children.!!Haitians’!perception!of!street!children!is!overwhelmingly!negative,!with!little!compassion!for!their!plight.!Street!children!are!seen!to!be!the!root!cause!of!urban!Haiti’s!crime!rate.!They!are!regarded!as!thieves,!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!843!U.S.!Department!of!State,!Trafficking&in&persons&report&2009,!Office!to!Monitor!and!Combat!Trafficking!in!Persons!(June!2009).!Available!at!http://www.state.gov/documents/organization/123357.pdf!!

844!UNICEF!Executive!Board,!Revised&country&programme&document:&Haiti&(200952011)&(2009).!Available!at!http://www.unicef.org/about/execboard/files/Haiti`FRS2009`revised_feb2010`English.pdf!

845!J.!C.!Kovats`Bernat,!“Anti`Gang,!arimaj,!and!the!war!on!street!children,”!Peace&Review!12/3!(2000),!pp.!415`421.!846!J.!C.!Bernat,!“Children!and!the!politics!of!violence!in!Haitian!context:!Statist!violence,!scarcity!and!street!child!agency!in!Port`au`Prince,”!Critique&of&Anthropology!19/2!(1999),!pp.!121`138.!


848!J.!C.!Kovats`Bernat,!“Anti`Gang,!arimaj,!and!the!war!on!street!children,”!Peace&Review!12/3!(2000),!pp.!415`421.!849!PAHO,!Health&in&the&Americas&2007:&Volume&II&–&countries:&Haiti!(2007).!Available!at!http://www.paho.org/hia/archivosvol2/paisesing/Haiti%20English.pdf!!




853!J.!C.!Kovats`Bernat,!“Anti`Gang,!arimaj,!and!the!war!on!street!children,”!Peace&Review!12/3!(2000),!pp.!415`421.!854!UN!Committee!on!the!Rights!of!the!Child,!Consideration!of!reports!submitted!by!state!parties!under!article!44!of!the!Convention:!Haiti,!UN!Doc.!CRC/C/51/Add.7!(2002).!Available!at!http://www.unhcr.org/refworld/docid/3df59ad34.html!


856!U.S.!Department!of!State,!Trafficking&in&persons&report&2009,!Office!to!Monitor!and!Combat!Trafficking!in!Persons!(June!2009).!Available!at!http://www.state.gov/documents/organization/123357.pdf!


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killers,!drug!dealers,!and!prostitutes.858859860!As!a!result,!little!action!was!taken!prior!to!the!earthquake!at!the! institutional! level! to! accommodate! these! children! and! develop! programs! and! policies! to! address!their!needs.!In!fact,!prior!to!the!earthquake,!street!children!were!often!denied!access!to!domestic!and!international! faith`based! orphanages,! due! to! the! perception! that! they! would! corrupt! the! other!children.861! Since! the! earthquake,! a! number! of! initiatives! have! been! undertaken! to! improve! this!situation.! UNICEF! is! supporting! the! establishment! of! residential! care! facilities,! both! “overnight”! and!permanent,! to!provide! street! children!with!an!entry`point! to! services!and! support—although!demand!far!out`strips!supply.862! In! July!2011,!President!Martelly!also!declared!his! intention!to!create!a! fund!to!support!programs!for!street!children!similar!to!the!National!Fund!for!Education,!though!further!details!have!not!been!released!as!of!this!writing.863!!To!cope!with!their!precarious!situation!and!ostracism,!Haitian!children! in!and!of!the!street!often!form!their! own! social! organizations! and! support! networks,! sharing! food! and! other! goods! between!members.864,865! In!essence,!these!groups!provide!a!social!safety!net!for!street!children!not!provided!by!formal! structures,! but! may! reinforce! negative! perceptions! of! street! children! participating! in! deviant!gang!activities.!!!Each! of! the! factors! driving! children! to! the! street! necessitates! a! different! response! to! alleviate! the!underlying!cause.!To!date,!policies!aimed!at!addressing!these!root!causes!have!met!with!little!success.!In!2002,!the!UN!Committee!on!the!Rights!of!the!Child!expected!the!number!of!street!children!to!increase!due! to! “the! growing! pauperization! in! the! country! and! the! continuous! migration! to! urban! areas.”866!Poverty!reduction!strategies!had! little!appreciable! impact!on!Haiti’s!standard!of! living!before!the!2010!earthquake,! despite! gains! in! some! areas.! Since! January! 2010,! poverty! reduction! and! increased!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!858!J.!Moncrieffe,!“When!labels!stigmatize:!Encounters!with!‘street!children’!and!‘restavecs’!in!Haiti,”!in!J.!Moncrief!and!R.!Eyben!(eds),!The&power&of&labelling:&How&people&are&categorized&and&why&it&matters!(London:!Earthscan,!2007).!


860!J.!C.!Bernat,!“Children!and!the!politics!of!violence!in!Haitian!context:!Statist!violence,!scarcity!and!street!child!agency!in!Portàu`Prince,”!Critique&of&Anthropology!19/2!(1999),!pp.!121`138.!

861!J.!Moncrieffe,!“When!labels!stigmatize:!Encounters!with!‘street!children’!and!‘restavecs’!in!Haiti,”!in!J.!Moncrief!and!R.!Eyben!(eds),!The&power&of&labelling:&How&people&are&categorized&and&why&it&matters!(London:!Earthscan,!2007).!

862!UNICEF,!Residential&care&center&provides&a&refuge&for&street&children&in&Cap5Haitian!(February!2011).!Available!at!http://www.unicef.org/infobycountry/haiti_57670.html!!

863!HaitiLibre,!"Martelly!working!on!a!fund!project!for!street!children,"!HaitiLibre!(July!6,!2011).!Available!at!http://www.haitilibre.com/en/news`3116`haiti`social`martelly`workingònà`fund`project`for`street`children.html!

864!J.!C.!Bernat,!“Children!and!the!politics!of!violence!in!Haitian!context:!Statist!violence,!scarcity!and!street!child!agency!in!Portàu`Prince,”!Critique&of&Anthropology!19/2!(1999),!pp.!121`138.!



!


opportunities! have! become! cornerstones! of! the! Post`Disaster! Action! Plan,867! raising! hopes! that! the!economic!motivation! for! children! to!move! to! the! streets,! either! voluntarily! or! at! the! behest! of! their!families,! will! be! reduced! over! time,! leading! to! a! reduced! number! of! street! children.! However,! it! is!unclear! how! the! earthquake! will! affect! Haiti’s! relationship! with! the! Dominican! Republic! in! terms! of!extradition!arrangements!that!leave!young!Haitians!at!the!border!without!a!support!network.!Similarly,!it! is!unlikely! that! the!earthquake!will!have! led!to!a!better!situation! for!children! in!domestic!servitude,!and! their! expulsion! or! flight! from! host! households! is! likely! to! remain! a! dominant! driver! for! children!turning!to!the!streets!to!meet!their!basic!needs.!


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6.&Poverty,&access,&and&empowerment&


6.&Poverty,&access,&and&empowerment&!Poverty!is!an!integral!risk!factor!for!many!undesirable!child!protection!outcomes.!The!notion!of!human!security,!with!its!dual!focus!on!freedom!from!fear!and!freedom!from!want,!underlies!the!link!between!deprivation! and! threats! to! children’s! basic! rights,! including! the! rights! to! life,! health,! education,! and!development.! In! 2005,! the! Haitian! Government! reported! that! approximately! 70%! (2.66! million)! of!children! lacked! access! to! basic! social! services! such! as! financial! resources,! food,! water,! shelter,! and!information.868,869! To! assess! the! impact! of! this! lack! of! access! on! child! protection,! it! is! necessary! to!examine! access! to! each! service! in! and! of! itself,! as!well! as! the! impact! of! that! lack! of! access! on! other!outcomes!of!concern.!!!!

A.&Monetary&poverty&!At!the!root!of!many!protection!challenges!facing!Haitian!children!is!widespread!monetary!poverty!that!has! undermined! development! and! delivery! of! services! and! support! to! those! in! need.! Shortages! of!financial! capital! at! the! state,! community,! and! household! levels! are! key! impediments! to! realizing! the!rights! of! Haitian! children.! Little! child`specific! information! exists! on! the! pervasiveness! and! impact! of!monetary! poverty! in! Haiti.! However,! because! children! are! dependent! on! their! families! for!means! of!financial!support,!and!because!those!households!at!the!lower!end!of!the!income!distribution!generally!have!more! children! than! those! of! higher! socio`economic! status,! this! Report! will! analyze! population`based!monetary!poverty!in!Haiti!with!a!focus!on!its!effects!on!Haitian!children’s!protection.!!The!most! commonly! used! indicators! of!monetary! poverty! are! the! proportion! of! people! living! on! less!than!US$1!or!US$2!per!day.!These!are!“headcount”!indicators,!in!that!they!assess!the!pervasiveness!of!poverty!but!not!its!depth.!The!enumeration!of!these!statistics!is!plagued!by!three!major!inconsistencies:!1)!the!specification!of!the!“base!year”!used!to!calculate!US$1!(against!which!the!value!of!US$1!can!be!said!to!increase!or!decrease!over!time!according!to!inflation),!2)!whether!or!not!Purchasing!Power!Parity!(PPP)!is!included!in!the!calculation!of!the!US$!equivalent!(so!that!differences!in!the!cost!of!basic!goods!between! countries! are! reflected),! and! 3)! the! definition! of! per! capita! income,! including! non`financial!income! (such! as! self`consumption! of! agricultural! produce).870! Although! these! and!many! other! factors!may!bias!the!calculation!of!such!indicators,!headcount!poverty!remains!the!most!pervasive!measure!of!national!poverty.!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!868!Technical!Secretariat!of!the!Preparatory!Committee,!Growth&and&poverty&reduction&strategy&paper:&Republic&of&Haiti.!IMF!country!report!08/115!(November!2007).!Available!at!http://www.imf.org/external/pubs/ft/scr/2008/cr08115.pdf!



!


!Despite! its! popularity! as! an! indicator! of! poverty,! few! nationally! representative! surveys! enumerating!headcount! poverty! proportions! have! been! conducted! in! Haiti.! International! databases,! such! as! the!World! Bank’s! World! Development! Indicator! database,871! the! DevInfo! MDG! database,872! UNESCO’s!Education! for! All! database,873! and! the! State! of! the!World’s! Children! database,874! cite! the! 2001! Haiti!Living! Conditions! Survey! (HLCS)! as! the! most! recent! and! reliable! estimate! of! poverty! nationwide.!According! to! the!2001!HLCS,!54.9%!of! the!Haitian!population! lived!on! less! than!US$1!per!day! in!2001!(US$1.25!in!2005!dollars),!adjusted!for!PPP.!It!was!also!estimated!that!72`76%!of!the!Haitian!population!lived! in!relative!poverty,!or!below!US!$2!per!day! in!2001.875,876,877,878!Since!2001,!but!prior! to! the!2010!earthquake,! the! percentage! of! people! living! in! absolute! and! relative! poverty! decreased! by!approximately!8%,!to!47%!living!on!less!than!US$1!per!day,!and!approximately!68%!living!on!less!than!US$2!per!day.879!!The!prevalence!of!monetary!poverty! is! far!higher! in!rural!areas!than! in!urban!areas,! in!general,!and! in!Portàu`Prince,!specifically.!According!to!the!IMF,!77%!of!people!living!on!less!than!US$1!per!day!were!rural!residents!in!2001,!while!9%!lived!in!the!Portàu`Prince!metropolitan!area,!and!14%!in!other!urban!areas.!Extreme!poverty!was!found!to!be!more!than!twice!as!prevalent!(67%)! in!rural!areas!than!in!the!Portàu`Prince!metropolitan! area! (23%),! while! other! urban! areas! were! between! these! two! extremes!(57%).!Discrepancies!between!urban!and!rural!areas!were!also!found!in!an!analysis!of!those!living!on!less!than!US$2!per!day,!with!88%!of!rural!residents!falling! into!this!category,!compared!to!45%!of!those!in!Portàu`Prince!and!76%! in!other!urban!areas.!The! IMF!attributes! these!discrepancies! to! the!economic!activities!engaged!in!by!rural!and!urban!residents.880!!Though! headcount! indicators! of!monetary! poverty! assess! the! population! with! regard! to! an! arbitrary!benchmark! (for! example,! US$1! per! day),! other! indicators! assess! the! distribution! of! income! within! a!population.!These! indicators! include!the!Gini!Coefficient,! the!share!of! income!held!by!population!sub`!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!871!World!Bank,!World&development&indicator&database.!Available!at!http://databank.worldbank.org/ddp/home.do?Step=12&id=4&CNO=2!


874!UNICEF,!State&of&the&world’s&children&database.!Available!at!http://www.unicef.org/statistics/index_step1.php!875!IMF,!Haiti:&Poverty&reduction&strategy&paper,!IMF!country!report!No.!09/290!(2009).!Available!at!http://www.imf.org/external/pubs/ft/scr/2009/cr09290.pdf!!






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groups,! and! the! proportion! of! people! within! disaggregated! income! bands.! The! Gini! coefficient! is! a!measure! of! income! inequality! within! a! population,! with! a! value! of! 0! indicating! complete! income!equality,! and! a! value! of! 1! indicating! that! a! single! person! controls! all! income.! As! such,! lower! Gini!coefficients!represent!more!equal!income!distributions.!Although!estimates!of!Haiti’s!Gini!coefficient!for!2001! vary! by! source,! all! reveal! an! extremely! unequal! distribution,! ranging! from! 0.59`0.66.881,882,883,884!This!range!indicates!that!Haiti’s!income!distribution!at!that!time!of!these!studies!had!approximate!parity!to!Brazil,! though!Haiti’s!average!per!capita! income!was! less.885!The! IMF!also!reports!a!deterioration!of!income! equality! in! Haiti! over! the! past! 25! years.886! However,! while! income! inequality! is! high! in! all!Departments,! it! is! not! uniform! countrywide.! It! was! observed! in! 2001! that! Artibonite! and! Nord`Est!Departments!had!the!largest!Gini!Coefficients!(0.698!and!0.697,!respectively),!while!Sud`Est!Department!displayed! the! lowest! (0.538)! (Figure! 59).887! Troublingly! for! policy`makers! concerned! with! poverty!reduction,! the! World! Bank! notes! that! “the! more! unequally! income! is! distributed,! the! less! effective!economic!growth!is!in!reducing!poverty.”888!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!881!UNESCO,!Education&for&all&database:&Haiti.!Available!at!http://www.uis.unesco.org/ev.php?URL_ID=5262&URL_DO=DO_TOPIC&URL_SECTION=201!











!


Figure.59:.Gini.indices,.by.Department.and.urban/rural.status,.2001*.

!*The!Gini!Index!is!the!Gini!Coefficient,!multiplied!by!100.!Source:!D.!Verner,!Making&poor&Haitians&count:&Poverty&in&rural&and&urban&Haiti&based&on&the&first&household&survey&


!!The! degree! of! income! inequality! in! Haiti! is! similarly! evident! when! assessing! the! proportion! of! total!income!held!by!subsets!of!the!population.!Figure!60!illustrates!the!share!of!income!held!by!the!lowest!and!highest!income!deciles!in!Haiti,!as!well!as!the!share!held!by!each!income!quintile!in!2001.!In!2001,!the!richest!10%!of!the!population!controlled!54!times!the!wealth!of!the!lowest!10%!in!that!year,!while!the! richest! quintile! controlled! 25! times! the! wealth! of! the! poorest! quintile.889!More! recent! estimates!indicate!that!this!situation!has!deteriorated!further!since!2001.!In!2008,!the!IMF!stated!that!the!richest!quintile!controlled!68%!of!the!nation’s!wealth!and!that!the!richest!2%!controlled!approximately!26%!of!the!nation’s!wealth,!while!the!poorest!80%!of!Haitians!controlled!only!32%!of!all!income.890!Similarly,!in!2010! the! Haitian! government! stated! that! the! richest! 10%! of! the! population! controlled! 50%! of! all!revenue.891!!Figure.60:.Income.share.held.by.quintile.and.extreme.deciles,.2001.

Income.share.held.by.

Lowest.10%.

Highest.10%.

Lowest.20%.

Second.20%.

Third.20%.

Fourth.20%.

Highest.20%.

0.88! 47.83! 2.53! 5.92! 10.48! 18.1! 62.97!

Data!source:!World!Bank,!World&development&indicator&database.!Available!at!http://databank.worldbank.org/ddp/home.do?Step=12&id=4&CNO=2!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!889!World!Bank,!World&development&indicator&database.!Available!at!http://databank.worldbank.org/ddp/home.do?Step=12&id=4&CNO=2!



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!As!Figure!61!shows,!moreover,!78.4%!of!Haitian!workers!earned!less!than!5,000!gourdes!(US$124!as!of!January! 18,! 2011)! per! month! in! 2008,! while! 44.7%! earned! less! than! 2,000! gourdes! (US$47.7! as! of!January! 18,! 2011).! The! monthly! income! distribution! has! remained! heavily! skewed! to! low`income!categories,! with! only! a! small! percentage! of! Haiti’s! population! earning! above! 20,000! gourdes! per!month.892!!Figure.61:.Monthly.income.(%),.2006.and.2008.

!Source:!IMF,!Haiti:&Poverty&reduction&strategy&paper,!IMF!country!report!No.!09/290!(2009).!Available!at!http://www.imf.org/external/pubs/ft/scr/2009/cr09290.pdf!!

!!Overabundance!of!unskilled!labor!in!Haiti!is!a!driving!factor!of!low!wage!levels!and!is!a!contributor!to!the!perpetuation!of!poverty!in!the!country.!Decades!of!high!population!growth!have!led!to!large!numbers!of!people! entering! their! working! ages,! which! has,! in! turn,! has! led! to! a! surplus! supply! of! labor.893! Two!consequences!of! this!phenomenon!have!been!downward!pressure!on!wages! for! those!who!have! jobs!and! decreasing! intensity! of! economic! activities! across! the! country.! Figure! 62! demonstrates! that! a!minority!of!the!working`age!population!engaged!in!economic!activities!each!day!in!2008,!which!reduced!the!monthly!income!of!those!with!jobs.!Due!to!these!factors,!Gross!Domestic!Product!(GDP)!per!capita,!expressed! in! 2005! U.S.! dollars! with! PPP! adjustment,! fell! from! $1,380! to! $1,165! over! the! 17! years!between!1991!and!2008.894!!



894!UNESCO,!Data&center:&Custom&tables:&Haiti.!Available!at!http://stats.uis.unesco.org/unesco/TableViewer/document.aspx?ReportId=136&IF_Language=eng&BR_Topic=0!

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Figure.62:.Intensity.of.household.economic.activity,.by.city,.2008.

CITY Total

Port-au-Prince

Cap-Haitian Gonaïves Saint-

Marc Petit-Goâve Port-au-Prince

Intensity of economic activity

Every day 31% 28% 30% 36% 34% 31% Sometimes 19% 17% 26% 27% 18% 20% No activity 50% 54% 43% 36% 48% 49%

Total N 771 267 167 121 119 1445 100% 100% 100% 100% 100% 100%


!!Figure.63:.GDP.per.capita,.expressed.in.2005.Purchasing.Power.ParityTadjusted.2005.U.S..dollars,.1991T2008.

!Data!source:!UNESCO,!Data&center:&Custom&tables:&Haiti.!Available!at!http://stats.uis.unesco.org/unesco/TableViewer/document.aspx?ReportId=136&IF_Language=eng&BR_Topic=0!

!!Low!per! capita! income! is! not! uniform! across!Haiti,!with! significant! differences! between!Departments!and! between! Portàu`Prince,! urban,! and! rural! areas! (Figure! 64).! Those! in! Portàu`Prince! had! a!significantly!higher!median!income!than!their!rural!and!other!urban!area!counterparts.!The!World!Bank!notes! that! for! any! position! on! the! income! distribution! (by! decile),! earnings! are! roughly! four! times!greater! in! the! Portàu`Prince! metropolitan! area! than! in! rural! areas.895! While! median! incomes! were!


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higher! in! the! urban! areas! of! six! Departments! than! in! rural! areas,! the! inverse! was! true! in! four!Departments.!Overall,!Nord`Est!Department!exhibited!the!lowest!median!per!capita!income!(US$671.7),!while!strong!performance!in!the!metropolitan!area!drove!the!Ouest!Department’s!dominance!(median!per!capita!income!of!US$4,366.7).896!!Figure.64:.Median.annual.income.per.capita,.by.Department.and.urban/rural/metropolitan.area.status,.2001.



!!Remittances!play!a!significant!role!in!Haitian!families’!livelihood!strategies!and!their!ability!to!overcome!monetary! poverty.! In! 2008,! 49.2%! of! Haitian! households! were! receiving! monetary! transfers! from!abroad,!an!increase!from!28.8%!in!2006.897!With!a!total!value!of!approximately!US$1.3!billion!in!2008,898!remittances! accounted! for! approximately! 19%! of! all! income! in! Haiti.899! Remittances! account! for! over!50%! of! income! inequality! relative! to! other! sources,! and! represent! a! substantial! proportion! of! Haiti’s!GDP.900!!In!addition!to!whether!the!family!receives!remittances!from!abroad,!several!other!factors!are!associated!with! the! probability! that! an! individual! or! household! will! be! in! monetary! poverty:! 1)!urban/rural/metropolitan!status,!2)!gender,!3)!age,!and!4)!level!of!education.!!







!


Though!rural!areas!account!for!a!larger!proportion!of!those!in!absolute!poverty!than!do!Portàu`Prince!and!other!urban!areas,!it!must!be!considered!that!rural!Haitians!account!for!a!greater!share!of!the!total!population! than!their!non`rural!counterparts.!Assessments!by! the!World!Bank!and!the! IMF!agree! that!once! this! population! differential! is! taken! into! account,! and! that! once! other! poverty! risk! factors! are!included! in! the! analysis,! urban/rural! status! is! not! in! itself! a! strong! determinant! of! monetary!poverty.901,902,903! According! to! the! IMF,! regional! status! accounts! for! 17%! of! all! inequality,!while! intra`regional!variation!accounts!for!approximately!83%.904!Verner!states!that!poor!access!to!services!is!highly!correlated!with!monetary!poverty,!which!explains!much!of!the!association!between!geographical!status!and!poverty!prevalence.905!!A! number! of! analyses! show! an! association! between! the! gender! of! the! head! of! household! and! the!probability! that! the!household!would!be! in!monetary!poverty.! In!2008,! the! IMF!observed! that!58%!of!households!in!which!females!were!the!main!incomeèarners!were!living!in!monetary!poverty,!compared!to!53%!of!households!where!males!were!the!primary!incomeèarners.!Differences!in!the!probability!of!household!monetary!poverty!based!on!the!head!of!household’s!sex!were!observed!in!metropolitan!(26%!female! versus! 17%!male)! and! other! urban! (64%! female! and! 48%!male)! households.906! Also! in! 2008,!Verner!noted!that!female`headed!households!in!rural!Haiti!were!8%!more!likely!to!live!in!poverty!than!their! male`headed! counterparts! (62%! of! female`headed! households! versus! 54%! of! male`headed!households).907!Counterìntuitively,!the!same!analyses!found!that!on!average,!women’s!median!income!was! 10%! higher! than! men’s! in! urban! areas.908,909! One! explanation! for! this! disparity! may! be! that!households!with!female!workers!are!more!concentrated!in!the!lowest!income!quintile,!as!women!have!a!higher! propensity! to! stop! working! as! household! income! rises.910! As! such,! women! may! be! over`










910!World!Bank,!A&review&of&gender&issues&in&the&Dominican&Republic,&Haiti&and&Jamaica,!Report!No.!21866`LAC!(2002).!Available!at!http://www`

&



represented! in! households! below! the!poverty! line,! despite! the! fact! that! those!who! are!working! have!higher!wages.!!Although!age!was!not!considered!to!be!a!strong!determinant!of!the!probability!of!monetary!poverty,!it!was! one! of! several! factors! taken! into! account! in! the! IMF’s! “Haiti:! Poverty! Reduction! Strategy! Paper”!(accounting!for!1%!of!all!variance).911!This!paper!found!that!households!headed!by!younger!people!were!less! likely! to! live! in!monetary!poverty! than!those!headed!by!older!people.!Of!households!whose!head!was!aged!24!or!under,!40%!were! in!absolute!poverty! in!2008,!compared!to!47%!of!those!headed!by!a!person!aged!25`44,!51%!of!those!headed!by!a!person!aged!45`65,!and!52%!for!those!headed!by!a!person!aged!66!or!older.912!!Education!is!the!strongest!factor!associated!with!poverty!reduction!in!Haiti.!Verner!states!that!all!levels!of!educational!attainment!are!significantly!associated!with!a!reduced!probability!of!an!individual!falling!into! monetary! poverty.! Monetary! returns! on! education! exponentially! increase! with! each! additional!institutional! level! attained.913! In! 2001,! the! World! Bank! observed! that,! “the! median! Haitian! worker!experiences!a!return!of!83,!203,!and!1,272!percent!for!having!completed!primary,!secondary,!and!their!tertiary!education.”914!This!phenomenon!is!discussed!further!in!Section!8C.&Education&engagement.!!Over!the!past!two!decades,!negative!economic!growth,!combined!with!high! inflation,!has!undermined!Haiti’s! ability! to! dramatically! decrease! the! proportion! of! the! population! living! in! poverty.915! Between!1990! and! 2009,! GDP! per! capita! fell! on! average! by! 2%! per! annum,! while! inflation! averaged! 18%.916!Recurrent! natural! disasters,! including! floods! in! 2004! and! hurricanes! in! 2008! (the! damage! of! which!totaled! approximately! 15%! of! Haiti’s! GDP),917! coupled! with! insecurity! and! political! unrest,! were!considered! to! be! the!main! drivers! of! poor! economic! performance! and! lack! of! investment! during! this!period.918,919! As! noted! previously,! even! if! macroeconomic! performance! had! improved! significantly,!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2003/03/22/000094946_03030704005682/Rendered/PDF/multi0page.pdf!!






916!UNICEF,!State&of&the&world’s&children&database.!Available!at!http://www.unicef.org/statistics/index_step1.php!917!IMF,!Haiti:&Poverty&reduction&strategy&paper,!IMF!country!report!No.!09/290!(2009).!Available!at!http://www.imf.org/external/pubs/ft/scr/2009/cr09290.pdf!!


!


Haiti’s! extremely! unequal! income! distribution! would! have! continued! to! limit! the! country’s! ability! to!translate!this!growth!into!poverty!reduction.920!!On!the!eve!of!the!January!2010!earthquake,!most!Haitians!were!extremely!vulnerable!to!income!shocks.!The!Haitian!government!points!out!that “most!Haitians!have!no!retirement!provision,!no!social!security!and!no!savings,”921!such!that!inability!to!find!work!for!even!a!short!period!of!time!can!be!disastrous!for!a!household’s! financial! situation.! Alarmingly,! a! rapid! assessment! by!World! Vision! from! February! 3`6! in!earthquakeàffected!areas!found!that!only!6%!of!household!members!were!receiving!any! income,!and!that!60%!of!families!had!lost!their!former!preèarthquake!livelihood!strategies.!As!a!result,!most!families!had!sold!assets!and!gone!into!debt!to!pay!for!consumption!goods,!such!as!water,!food!and!healthcare.922!!The!Haitian!government!estimated!that,!after!some!improvement!since!2007,!the!earthquake!returned!poverty!prevalence!to!the!level!found!in!2001,!with!71%!of!people!living!on!less!than!US$2!per!day!and!50%! living! on! less! than! US$1! per! day.923! However,! these! headcount! measures! failed! to! accurately!characterize! the! situation,! as! those! both! below! and! above! the! poverty! line! were! devastated! by! the!earthquake.!!!In!March!2010,!a! rapid!Emergency!Food!Security!Assessment! (EFSA)!conducted!by! the!Government!of!Haiti’s! National! Food! Security! Coordination! Unit! (Coordination& Nationale& de& la& Sécurité& Alimentaire! `!CNSA)! in! earthquakeàffected! areas! found! that! 48%! of! the! population! was! poorer! as! a! result! of! the!earthquake,! with! a! higher! proportion! of! households! in! camps! reporting! being! poorer! after! the!earthquake! in!both!urban! (78%!were!poorer)! and! rural! areas! (70%!were!poorer)! than! the!average.924!Haitian! families’! ability! to! provide! for! their! children’s! rights! is! heavily! determined! by! their! access! to!financial! and! other! resources.! The! reduction! in! income! of! almost! half! of! households! in! earthquakeàffected!areas!has!compounded!preèxisting!endemic!poverty,!preventing!many!families!from!accessing!goods!and!services!necessary!for!their!children’s!safety!and!overall!development.!The!CNSA’s!rapid!food!security! assessment! found! that! by!March!2010,! an! additional! 20%!of! surveyed!households!were!now!categorized! as! “poor”! than!before! the!earthquake! (52%! compared! to!32%),! based!on!preèarthquake!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!919!D.!Verner,!Making&poor&Haitians&count:&Poverty&in&rural&and&urban&Haiti&based&on&the&first&household&survey&for&







&



wealth! terciles,! and! that! fewer! were! categorized! as! “average”! (30%! versus! 35%)! or! “wealthy”! (18%!versus!34%)!(Figure!65).925!!Figure.65:.HouseholdTlevel.monetary.effects.of.the.earthquake.in.affected.areas,.by.preTearthquake.income.tercile,.March.2010.

!Source:!CNSA,!Rapid&post5earthquake&emergency&food&security&assessment:&Haiti!(March!2010).!Available!at!http://documents.wfp.org/stellent/groups/public/documents/ena/wfp221395.pdf!

!!

B.&Food&security&and&nutrition&!The! right! to! food! is! a!basic!human! right.!Undernourishment! can! lead! to!delayed!motor!development,!poor! cognitive! development,! poor! growth,! and! greater! vulnerability! to! infection! and! disease.926,927! In!Haiti,!pervasive!poverty!and!inadequate!healthcare!facility!distribution!mean!that!most!undernourished!children!are!unable!to!access!health!services!when!they!become!sick,!and!malnourishment!is!associated!with!more!than!50%!of!childhood!deaths!(See!Section!7A.&Healthcare&access).928!Those!who!survive!are!faced!with!even!greater!risk!of!recurrent!sickness!and!morbidity!due!to!their!bodies’!depleted!capacity,!contributing!to! irreversible!damage.!Additionally,!failure!to!achieve!the!basic!right!to!food!undermines!children’s! ability! to! enjoy! other! rights,! such! as! the! right! to! education! (MDG! 2).929! Malnutrition! and!undernutrition! refer! to! various! related! phenomena,! including! hunger,! macro`,! and! micro`nutrient!deficiencies,! which! in! turn! present! as! outcomes! including! stunting,! wasting,! and! social! and! cognitive!


926!UNICEF,!Progress&for&children&number&4:&A&report&card&on&nutrition!(May!2006).!Available!at!http://www.unicef.org/progressforchildren/2006n4/files/PFC4_EN_8X11.pdf!!



929!UNICEF,!Progress&for&children&number&4:&A&report&card&on&nutrition!(May!2006).!Available!at!http://www.unicef.org/progressforchildren/2006n4/files/PFC4_EN_8X11.pdf!!

!


deficiencies.! Although! nutrition! is! a! component! of! the! definition! of! food! security,! it! can! also! be!programmatically! considered! in! terms! of! the! biological! effects! of! consuming! foods! of! varying! quality.!Food!security,!in!contrast,!is!a!broader!concept,!including!access!and!cultural!context,!defined!by!the!UN!Food!and!Agriculture!Organization!as:!!

…a!situation!that!exists!when!all!people,!at!all!times,!have!physical,!social!and!economic!access!to!sufficient,!safe!and!nutritious!food!that!meets!their!dietary!needs!and!food!preferences!for!an!active!and!healthy!life.930&

!Prior!to!the!January!2010!earthquake,!Haiti!had!not!realized!its!constitutional!and!human!rights!to!food;!instead!the!country’s!population!experienced!chronic!mal`!and!undernutrition,!and!insufficient!access!to!food.931! In!2007,!only!one! fifth!of!households!reported! that! they!were!able! to!meet! their! food!needs,!with!Port`au`Prince!households!better!equipped!to!meet!their!basic!needs!(33%)!than!rural!households!(13.1%).932!Food!consumption!was!also!found!to!be!highly!elastic!with!changes!in! income,!with!32%!of!households! declaring! that! increasing! their! food! consumption! would! be! their! first! priority! after! an!increase! in! income,! while! most! households! stated! that! reducing! food! consumption! is! their! primary!course!of!action!in!times!of!financial!strife.933!!Estimates! of! the! proportion! of! the! population! living! with! food! insecurity! differ! by! source! and! time!period,! making! it! difficult! to! draw! conclusions! about! the! direction! of! trend.! One! cause! of! these!discrepancies!may!be!the!lack!of!consensus!on!an!operational!and!assessment!definition!of!the!concept,!although!the!World!Food!Program!(WFP)!has!attempted!to!remedy!this!shortcoming.934!!Most!sources!at!the!time!of!the!January!2010!earthquake!cited!a!2007!PAHO!estimate!of!the!prevalence!of! food! insecurity! that! suggested! 40%! of! Haitian! households! were! food! insecure.935,936,937! Other! pre`earthquake!estimates!vary!considerably,!though!this!variance!may!be!the!result!of!changes!over!time!or!external!factors,!such!as!droughts!and!hurricanes.!In!2004,!the!Haitian!government!had!estimated!that!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!930!FAO,!The&state&of&food&insecurity&in&the&world&2001!(2001).!Available!at!http://www.fao.org/docrep/003/y1500e/y1500e00.htm!!




934!World!Food!Program,!Food&security&analysis!(2010).!Available!at!http://www.wfp.org/food`security!!935!PAHO,!Health&in&the&Americas&2007:&Volume&II&–&countries:&Haiti!(2007).!Available!at!http://www.paho.org/hia/archivosvol2/paisesing/Haiti%20English.pdf!!



&



approximately!two!thirds!of!rural!households!were!severely!food!insecure.938!In!2009,!Oxfam!estimated!that!approximately!one!third!of!Haitian!households!were!food!insecure.939!An!assessment!by!the!World!Food!Program! in! the!Sud`Est!Department! found! that!17%!of!households!were!either! severely! (5%)!or!moderately!(12%)!food!insecure!in!Jacmel!on!the!eve!of!the!earthquake,!while!2`3%!were!severely!food!insecure!and!12`17%!moderately!food!insecure!in!rural!areas.940!In!comparison,!similar!WFP!assessments!in!Port`au`Prince!in!2008!and!rural!areas! in!2007!found!that!14%!and!6%!of!households!were!severely!food!insecure,!and!an!additional!17%!and!19%!were!moderately!food!insecure,!respectively.941!!!Prior! to! the! earthquake,! a! survey! of! Haitian! households! found! that! 11%! identified! food! insecurity! as!their! greatest! challenge,! second! only! to! unemployment! (28%).942! Unstable! income! sources,! lack! of!domestic! production,! low! purchasing! power! and! the! lack! of! fallback! food! strategies! contributed! to!households’!vulnerability.943!On!the!eve!of!the!earthquake,!only!44%!of!the!population!had!food!stocks,!illustrating! the! limited! ability! of! the! population! to! absorb! shocks! to! their! access! to! food.944! A! 2002!review!by!the!World!Bank!found!that!male`headed!rural!households!were!four!times!more!likely!to!be!extremely! food! insecure! than! female`headed! households.!However,!when! severe! and!moderate! food!insecurity! were! considered! together,! differences! between! the! food! security! situation! of! households!headed!by!men!and!women!were!negligible.945!!Measures! of! childhood! malnutrition! have! been! more! consistent! than! estimates! of! food! insecurity,!perhaps!due! to!better!articulation!of!measurement!standards!and! indicators.!Most!sources!have!used!statistics!derived!from!the!suite!of!nationally!representative!EMMUS!surveys!conducted!in!1990!(I),!1995!(II),! 2000! (III),! and! 2005/06! (IV)! (Figure! 66).946,947,948,949,950,951,952,953,954,955! Over! this! 15`year! period,! the!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!938!Government!of!Haiti,!Interim&cooperation&framework&200452006:&Summary&report!(2004).!Available!at!http://haiticci.undg.org/uploads/ReportVersion8%20Eng%20FINAL%20Low%20Res.pdf!!

939!Oxfam!International,!Haiti:&‘A&gathering&storm’:&Climate&change&and&poverty!(November!2009).!Available!at!http://www.oxfam.org/en/policy/haiti`gathering`storm!!

940!CNSA,!Rapid&post5earthquake&emergency&food&security&assessment:&Haiti!(March!2010).!Available!at!http://documents.wfp.org/stellent/groups/public/documents/ena/wfp221395.pdf!!








!


prevalence!of!Global!Acute!Malnutrition!(GAM)!in!children!under!five!years!of!age!has!fluctuated,!with!2006! witnessing! the! highest! recorded! proportion! (9.1%).! Fewer! data! are! available! on! Severe! Acute!Malnutrition!(SAM),!but!prevalence!estimates!for!2000!and!2006!also!show!an!increase!in!those!years,!from!0.6%! to! 2.2%.!Unlike! estimates!of! acute!malnutrition,! chronic!malnutrition!declined! significantly!over!the!period,!from!33.9%!in!1990!to!23.8%!in!2006,!but!witnessed!an!upturn!at!the!end!of!the!period.!The! proportion! of! children! under! five!who!were! underweight! also! fluctuated,! but!was! lower! in! 2006!(22.2%)! than! in!1990! (26.8%).!Rather! than!consistent! trends!over! time,! the! results! indicate! that!acute!interruptions! in! the! availability! and! accessibility! of! food! stemming! from! domestic! and! international!events,!such!as!sporadic!periods!of!violence!and!the!imposition!of!international!sanctions!in!1991,956,957!were!the!driving!factors!behind!poor!nutritional!outcomes.!!More! recent! estimates! suggest! that! the! nutritional! situation! of! children! under! age! five! continued! to!decline!between!2006!and!the!eve!of!the!earthquake.!In!2008/09,!it!was!estimated!that!the!prevalence!of!SAM!had!risen!to!4.5%,!the!prevalence!of!GAM!had!risen!to!10%,!and!30%!of!Haitian!children!were!chronically!malnourished.958,959,960,961!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!948!IMF,!Haiti:&Poverty&reduction&strategy&paper,!IMF!country!report!No.!08/115!(2008).!Available!at!http://www.imf.org/external/pubs/ft/scr/2008/cr08115.pdf!!





952!WHO!CRED,!Haiti:&A&brief&analysis&of&surveys&from&2004&to&2005,!Briefing!note!243,!Complex!Emergency!Database!(March!2008).!Available!at!http://www.cedat.be/sites/default/files/Brief%20243%20`%20Haiti.pdf!


954!Government!of!Haiti,!Interim&cooperation&framework&200452006:&Summary&report!(2004).!Available!at!http://haiticci.undg.org/uploads/ReportVersion8%20Eng%20FINAL%20Low%20Res.pdf!!



956!M.!Baro,!“Food!insecurity!and!livelihood!systems!in!northwest!Haiti,”!Journal&of&Political&Ecology!9!(2002),!pp.!1`34.!





961!Save!the!Children,!Serving&Haiti’s&children&now,&rebuilding&for&their&future:&Six&months&after&the&massive&quake!(July!2010).!Available!at!http://www.savethechildren.org/atf/cf/{9def2ebe`10ae`432c`9bd0`df91d2eba74a}/Haiti_6_month_report.pdf!!

&



!Although! pockets! of! food! insecurity,! malnutrition! and! under`nutrition! are! present! across! Haiti,! rural!areas!typically!display!higher!rates!than!urban!areas.962,963!In!2008,!the!IMF!stated!that!acute!and!chronic!malnutrition!were!twice!as!prevalent!in!rural!areas!as!in!Port`au`Prince.964!Artibonite!and!Sud!emerged!as!the!Departments!with!the!highest!prevalence!of!Global!Acute!Malnutrition!(GAM)!(10%!and!12.1%,!respectively)!and!Severe!Acute!Malnutrition! (SAM)! (3.1%!and!4.4%,! respectively)! in!2006,!while!Ouest!Department!also!recorded!high!prevalence!of!SAM!(2.3%).965!!Figure.66:.Prevalence.of.underT5.malnutrition.and.undernutrition,.1990T2006.

Indicator. 1990. 1995. 2000. 2006.Global.Acute.Malnutrition.

(GAM).3.4! 7.8! 4.5! 9.1!

Severe.Acute.Malnutrition.(SAM).

! ! 0.6! 2.2!

Chronic.Malnutrition. 33.9! 31.9! 22.7! 23.8!Underweight. 26.8! 27.5! 17.3! 22.2!

Data!sources:!WHO!CRED,!Haiti:&A&brief&analysis&of&surveys&from&2004&to&2005,!Briefing!note!243,!Complex!Emergency!Database!(March!2008).!Available!at!http://www.cedat.be/sites/default/files/Brief%20243%20`%20Haiti.pdf;!D.!Verner,!Making&poor&Haitians&count:&Poverty&in&rural&and&urban&Haiti&based&on&the&first&

household&survey&for&Haiti,!World!Bank!Sustainable!Development!Division!(March!2008).!Available!at!http://go.worldbank.org/AE6TJ7EPY0;!IMF,!Haiti:&Poverty&reduction&strategy&paper,!IMF!country!report!No.!09/290!(2009).!Available!at!http://www.imf.org/external/pubs/ft/scr/2009/cr09290.pdf!

!!Haitian!children’s!poor!nutritional!status!begins! from!birth.!UNICEF!states!that!before!the!earthquake,!25%!of!children!were!of!low!birth!weight.!Additionally,!though!breastfeeding!was!widespread!(estimated!at!96%!in!1995),966!PAHO!noted!in!2007!that!exclusive!breastfeeding!was!low,!at!an!estimated!46%.967,968!!









968!Save!the!Children,!Serving&Haiti’s&children&now,&rebuilding&for&their&future:&Six&months&after&the&massive&quake!(July!2010).!Available!at!http://www.savethechildren.org/atf/cf/{9def2ebe`10ae`432c`9bd0`df91d2eba74a}/Haiti_6_month_report.pdf!!

!


A! number! of! surveys! have! found! that! a! large! proportion! of! children! in! Haiti! also! suffer! from!micronutrient! deficiencies,! especially! vitamin! A! and! iodine! deficiencies! and! anemia.! In! 2005,! it! was!found! that! 33%! of! children! under! five! had! a! vitamin! A! deficiency,! and! that! 1.47%! had! a! severe!deficiency.969,970,971!In!addition,!59%!of!children!aged!6!to!12!suffered!from!iodine!deficiency,!with!rural!areas!exhibiting!a!higher!prevalence!than!their!urban!counterparts.972,973!Most!troublingly,!it!was!found!that!in!2000,!65.3%!of!children!under!five!were!anemic.974,975!By!2005,!this!proportion!had!fallen!slightly!to! 61%;! however! it! is! unclear!whether! this! level! has! been!maintained,! fallen,! or!whether! gains! have!continued!over!time.976,977,978,979!!Haitian! households! spend! a! significant! proportion! of! their! income! on! food.! In! 1999/2000,! food!expenditure!accounted!for!55%!of!total!household!expenditure.980!By!2008,!this!proportion!had!declined!slightly!to!47.5%,!with!significant!differences!between!residents!of!Port`au`Prince!(32.8%),!other!urban!(41%),! and! rural! (55.6%)! areas.981,982! For! the! poorest! income!quintile! across!Haiti,! food! accounted! for!53.4%!of!household!income!in!2008,!while!it!accounted!for!only!9.8%!of!income!for!those!in!the!richest!quintile.983! For! those! in! lower! income! categories,! economic! constraints! severely! limit! access! to! food,!contributing!to!the!population’s!lack!of!food!security!and!poor!nutritional!outcomes.!!
















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In!December!2008,!a!survey!conducted!by!Crabtree,!Godoy,!and!Ray!found!that!60%!of!respondents!did!not!have!enough!money!to!buy!sufficient!food!in!the!preceding!12!months.!As!reflected!by!the!share!of!household! income!dedicated!to! food,! the!cost!of!basic! items! is!a!significant!burden!to!many.! In!2008,!price!increases!associated!with!the!global!food!crisis!led!to!civil!unrest,!resulted!in!the!deaths!of!several!people,!and!contributed!to!the!fall!of!the!government.984!The!same!year,!60%!of!the!domestic!harvest!was!destroyed!by!three!hurricanes!and!one!tropical!storm.985,986!Not!only!did!this!destruction!decrease!the!domestic!supply!of!staple!foods!(which!accounts!for!only!45`50%!of!Haiti’s!total!food!needs987,988,989),!but!also!destroyed!the!livelihood!strategy!of!farmers,!who!were!then!left!with!little!or!no!income!from!the! harvest.! The! vulnerability! of! Haitian’s! access! to! food,! due! to! the! high! cost! relative! to! household!incomes!and!the!vulnerability!of!domestic!food!supply,!testifies!to!the!low!level!of!food!security!of!most!Haitians.990!!Following! the! 2010! earthquake,! surveyed! Haitians! identified! food! as! their! highest! priority! (Figure!67).991,992! The! rapid! Emergency! Food! Security!Assessment! (EFSA)! found! that! 31%!of! the!population!of!earthquake`affected!areas!had!poor!or!borderline!food!consumption!(Figure!68).!Differences!were!also!observed!between!those!displaced!by!the!earthquake!(43%)!and!those!not!displaced!(27%).993!!











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Figure.67:.PostTearthquake.household.priorities,.by.region,.February.2010.


!!Figure.68:.Food.consumption.among.displaced.and.nonTdisplaced.earthquakeTaffected.residents,.February.2010.


!!Official!estimates!state!that!food!insecurity!in!earthquake`affected!areas!increased!from!40%!before!the!earthquake!to!52%!by!March!2010.994,995! In!large!IDP!camps,!this!figure!was!approximately!69%.996!The!University!of!Michigan/Small!Arms!Survey!placed!these!figures!higher,!estimating!that!10.9%!of!Port`au`Prince!households!were! food! insecure!with! severe!hunger,!32.8%!with!moderate!hunger,!31.5%!were!food! insecure!without!hunger,!and!only!23.6%!were! food!secure.!Among!camp!households,!only!4.4%!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!994!Government!of!Haiti,!Haiti&earthquake&PDNA:&Assessment&of&damage,&losses,&general&and&sectoral&needs!(March!2010).!Available!at!http://siteresources.worldbank.org/INTLAC/Resources/PDNA_Haiti`2010_Working_Document_EN.pdf!



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were!either!food!insecure!without!hunger!or!food!secure,!while!68.9%!were!food!insecure!with!severe!hunger! and! an! additional! 26.7%! were! food! insecure! with! moderate! hunger.997! The! proportion! of!households! with! food! stocks! fell! markedly,! with! only! 17%! reporting! food! stocks! postèarthquake!compared!to!44%!before.998!!Food! insecurity! remains! a! significant! concern! two! years! after! the! 2010! earthquake.! According! to! a!recent!national!food!security!survey!conducted!by!Food!Cluster!partners,!4.5!million!Haitians,!or!almost!half!of! the!total!population,!was!food! insecure!one!and!a!half!years!after!the!earthquake.!NordÒuest!and!NordÈst!Departments!and!Portàu`Prince!were!particularly!affected.999!!Food!security!in!postèarthquake!Haiti!has!been!associated!with!several!factors.!Those!households!who!had!changed!their!sources!of! income!since!the!earthquake,!for!example,!were!more! likely!(63%)!to!be!food!insecure!than!those!who!had!not!(44%).!Households!headed!by!women!were!also!more!likely!to!be!food!insecure!(60%)!than!male`headed!households!(45%).1000!Remittances!also!appeared!to!play!a!role.!Almost! 75%! of! food! secure! households! received! gifts! or! remittances,! while! 0%! of! food! insecure!household!with!severe!hunger!did.1001!Income!was!a!protective!factor!as!well,!with!households!receiving!any!income!approximately!half!as!likely!to!be!experiencing!food!insecurity!with!severe!hunger!(5%)!than!average.1002!!In! March! 2010,! the! EFSA! found! that! levels! of! acute! malnutrition! remained! below! Sphere! standard!emergency! thresholds.! According! to! the! survey,! 6%! of! children! under! five! suffered! from!GAM,!while!1.3%! suffered! from! SAM.1003,1004! The! prevalence! of! child! malnutrition! was! estimated! to! be! higher! in!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!997!A.!R.!Kolbe,!R.!Muggah,!R.!A.!Hutson,!et!al.,!Assessing&needs&after&the&quake:&Preliminary&findings&from&a&



999!UN!OCHA,!Humanitarian&bulletin:&19&August&–&20&September&2011!(September!2011).!Available!at!http://haiti.humanitarianresponse.info/LinkClick.aspx?link=Nutrition+Cluster%2f19_Aout_20_Septembre_2011_Haiti+_Humanitarian_Bulletin+10+English.pdf&tabid=80&mid=1033!!







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displaced!and!camp!populations,!although!sample!size! limitations!prevented!confident!sub`population!estimates.1005!Though!most!sources!refer!to!postèarthquake!levels!as!either!similar!to,!or!slightly!more!than,!GAM!and! SAM! levels! in! preèarthquake!Haiti,1006,1007! EMMUS! IV! survey! results! from!2006! (9.1%!GAM!&!2.2%!SAM,!respectively)!and!estimates! from!2008! (10%!&!4.5%,! respectively)! indicated!higher!levels.! If! the! EFSA! results! are! accurate,! this! would! suggest! that! the! prevalence! of! child! malnutrition!decreased! between! 2008! and! 2010,! though! the! challenging! nature! of! post`disaster! population`based!surveys!necessitates!caution!for!this!observation.!!As! part! of! its! surveillance! activities,! the!Nutrition! Cluster! introduced! an! active! screening! program! for!malnutrition! across! eight! Departments.! By! October! 2011,! 393,000! children! had! been! screened,! with!results! indicating! heterogeneous! levels! of! moderate! and! severe! malnutrition.! Across! all! surveyed!Departments,! 1.1%! of! children! were! found! to! be! severely! malnourished! (4,241! children)! and! 7.4%!moderately! malnourished! (28,260).! Severe! malnutrition! was! found! to! be! highest! in! Artibonite,!Grande‘Anse,!Nord,!Ouest!and!Sud!Departments!(Figure!69),!while!moderate!malnutrition!was!highest!in!Grande‘Anse,!Nippes,!Nord,!Ouest,!and!SudÈst!Departments!(Figure!70).1008!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1004!UNICEF,!Children&of&Haiti:&Progress,&gaps&and&plans&in&humanitarian&action!(April!2010).!Available!at!http://www.unicef.org/romania/FINAL_UNICEF_Haiti_90`Day_Report_13_April_2010_FINAL.pdf!!





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Figure.69:.Prevalence.of.severe.malnutrition.in.mostTaffected.Departments,.by.surveyed.commune,.JanuaryTOctober.2011.

!Source:!Haiti!Nutrition!Cluster,!Nutrition&cluster&update:&Issue&3!(October!2011).!Available!at!http://haiti.humanitarianresponse.info/LinkClick.aspx?link=English+Nutrition+cluster+update+issue+3.pdf&tabid=80&mid=1631!!

!!Figure.70:.Prevalence.of.moderate.malnutrition.in.mostTaffected.Departments,.by.surveyed.commune,.JanuaryTOctober.2011.


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!The!destruction!of!infrastructure,!logistics!capacity,!and!food!stores!led!to!a!significant!rise!in!the!price!of! basic! foods! following! the!earthquake,! limiting! access! and!placing! additional! strain!on! the! ability! of!families! to! meet! food! needs.1009! Before! the! earthquake,! imported! rice! in! Port`au`Prince! cost! 120!gourdes!per!6!pounds.!This!price!increased!to!almost!160!gourdes!by!26!January!2010!before!stabilizing!at! 150! gourdes! per! 6! pounds! by! 11! February! 2010! (Figure! 71).1010,1011! Immediately! following! the!earthquake,! the! extremely! low! proportion! of! earthquake! survivors! bringing! in! any! income! (6%)!compounded!the!impact!of!these!price!increases.1012!!Figure.71:.Price.of.basic.foodstuffs.in.PortTauTPrince.and.Jacmel,.November.2009TFebruary.2010.


!!Increased!prices!and!decreased!income!meant!households!turned!to!other!survival!strategies,!including!going! into! debt.! In! March! 2010,! the! Haitian! government! estimated! that! more! than! half! of! all!





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earthquakeàffected!households!had!become!severely! indebted,!with!95%!of! this!debt!accrued!to!pay!for!food.1013,1014!

!The!EFSA!found!that!Haitians’!survival!strategies!were!related!to!preèarthquake!livelihood!strategies.!As!such,! those! in! rural! areas! reported! high! rates! of! eating! seed! stocks! (51%),! harvesting! earlier! (39%),!refraining! from! buying! any! or! sufficient! farm! inputs! (35%),! and! selling! additional! livestock! (32%).! In!urban! areas,! households! typically! continued! to! look! for! temporary! work,! sell! assets,! or! consider!migrating.1015,1016,1017!In!addition!to!these!strategies,!most!families!reduced!the!amount!of!food!they!ate,!thus! reducing! expenditures.! In! early! February! 2010,! 87%!of! households! in! Portàu`Prince! and! 92%!of!earthquakeàffected!households! in! the!outskirts!of! the! capital! reported! that!household!members!had!decreased! food! consumption! by! one! or! more! meals! a! day.1018! For! children,! this! reduced! level! of!consumption!would!mean!heightened!malnutrition!and!vulnerability!to!disease,!as!well!as!risk!of! long`term!damage.!!Of! concern! to! child!protection!programmers!was! the! finding! that!many! families! sent! their! children! to!rural! family! members! and! friends! following! the! earthquake! to! provide! for! their! food! needs.! This!phenomenon!was!reportedly!higher!for!camp`based!populations.!EFSA!authors!noted!that!this!strategy!does! not! necessarily! pose! a! problem! if! the! children’s! host! families! provide! adequate! care! and! return!children! to! their! families! once! their! needs! are! met.! However,! some! community! members! raised!concerns!that!temporary!placement!can!result!in!a!restavek!arrangement,!discussed!in!further!detail!in!Section!9A.&Children&in&domestic&service&and&servitude.1019!!In!response!to!the!poor!food!security!of,!and!high!levels!of!malnutrition!among,!Haitian!children,!after!the! earthquake! UNICEF! and! its! partners! established! therapeutic! feeding! programs,! distributed!supplementary!food!and!infant!formula!for!pregnant!and!lactating!women,!created!and!scaled!a!school!meal! program,! provided! blanket! feeding! programs,! vitamin! A! supplementation,! and! trained! health!professionals! and! community! workers.! By! July! 2010,! 1,500! severely!malnourished! children! had! been!treated,! 500,000! children! under! five! had! received! supplementary! foods,! 3,000! babies! had! received!infant! formula,! 800,000! students! had! been! covered! by! the! school! meal! program,! and! 500! health!






1018!CDC,!CDC&summary&of&initial&rapid&assessment&conducted&by&UN&OCHA&in&Haiti!(February!2010).!1019!CNSA,!Rapid&post5earthquake&emergency&food&security&assessment:&Haiti!(March!2010).!Available!at!http://documents.wfp.org/stellent/groups/public/documents/ena/wfp221395.pdf!

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workers! had! been! trained.! By! the! end! of! 2010,! Vitamin! A! supplementation! was! projected! to! reach!253,000!children.1020,1021!!

In! the! period! between! September! 2010! and! August! 2011,! 14,128! children! were! admitted! to! 294!Outpatient!Feeding!Programs!(OTP),!68,743!children!to!369!Stabilization!Centers!(SC),!and!2,061!children!to! Therapeutic! Feeding! Centers! (TFC).1022! Performance! indicators! of! these! programs! and! centers!highlight! the! success! of! these! initiatives,! with! mortality! rates! below! benchmark! thresholds! for! all!programs.!Importantly,!the!Nutrition!Cluster!plans!to!further!expand!the!number!of!OTPs,!SCs,!and!TFCs!across!Haiti,!with!hopes!of!extending!benefits!of!such!programs!to!a! larger!number!of!Haitian!children!(Figure!72).1023!The!Haitian!government!has!identified!the!strengthening!of!long`term!initiatives,!such!as!the!national!health!workforce,!as!main!priorities!for!the!reconstruction!process.1024!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1020!UN!MINUSTAH,!Haiti:&6&months&after…!(July!2010).!Available!at!http://www.un.org/en/peacekeeping/missions/minustah/documents/6_months_after_commemoration.pdf!!





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Figure.72:.Priority.areas.for.nutrition.interventions,.by.commune,.October.2011.


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C.&Water,&sanitation,&and&hygiene&!Lack! of! access! to! safe!water! and! sanitation! facilities! are! key! risk! factors! for! childhood!morbidity! and!mortality.! In! 1999,! gastrointestinal! infection! was! the! leading! cause! of! death! of! children! under! five,!diarrhea!was! the!second! leading!cause!of!death!overall,! and!80%!of!diseases! impacting!children!were!water`borne.1025,1026! Inadequate!clean!drinking!water! is!a!key!driver!of!childhood! illness,1027!and!Haiti’s!surface!water! is!often!contaminated!with!household!excreta!and!other!contaminants.1028!Due! to! their!status!as!Millennium!Development!Goals,!access! to!water!and!sanitation!have!been!better!monitored!than!many!other!child!protection!risk!factors,!but!must!still!be!expanded!in!Haiti!to!achieve!the!holistic!protection!of!children.!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1025!M.!K.!Varma,!M.!L.!Satterthwaite,!A.!M.!Klasing,!et!al.,!“Woch!nan!soley:!The!denial!of!the!right!to!water!in!Haiti,”!Health&and&Human&Rights!10/2!(2008),!pp.!67`89.!

1026!IFRC,!Haiti:&Earthquake&three&month&progress&report!(April!2010).!Available!at!http://www.ifrc.org/docs/appeals/10/MDRHT00814.pdf!!

1027!Technical!Secretariat!of!the!Preparatory!Committee,!Growth&and&poverty&reduction&strategy&paper:&Republic&of&Haiti.!IMF!country!report!08/115!(November!2007).!Available!at!http://www.imf.org/external/pubs/ft/scr/2008/cr08115.pdf!


October 2011 SERVICE COVERAGE MAP

The map below was prepared for the CAP 2012 to highlight priority areas s ll in need of investment and interven on. The map should help to guide alloca on of re-‐sources based on residual needs and gaps. Needs highlighted in the map refer to the minimum service coverage planned to cover popula on needs in normal mes and in recurrent emergency situa ons and are indica ve. Priori sa on is based on minimum capacity of therapeu c care for severe malnutri on and areas of high food insecurity risk.

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!Most!international!databases!agree!that!58%!of!Haiti’s!population!used!improved!drinking!water!sources!in! 2006,! with! significant! differences! between! urban! (70%)! and! rural! (51%)!areas.1029,1030,1031,1032,1033,1034,1035!From!1990`2006,!total!access!to!an!improved!water!source!increased!by!6%,! from!52%! in!1990! to!58%! in!2006,!with!a!greater! increase! in!urban! (8%)! than! in! rural! areas! (3%)!(Figure! 73).! The! IMF! estimated! slightly! lower! access! to! improved! water! sources,! estimating! 55.2%!coverage!in!urban!areas!in!2006.1036!The!Haitian!government!reported!that!access!to!clean!water!did!not!change! appreciably! between! 2006! and! 2008,1037! while! the! Millennium! Project! stated! that! by! 2010,!coverage!had!improved!to!63%!overall,!71%!in!urban!areas,!and!55%!in!rural!areas.1038!In!2002,!a!global!review! conducted! by! Lawrence,! Meigh,! and! Sullivan! ranked! Haiti! the! poorest! performer! out! of! 147!countries!assessed!according!to!their!Water!Poverty!Index.1039!!


1030!Population!Reference!Bureau,!PRB&datafinder:&Haiti.!Available!at!http://www.prb.org/datafinder.aspx.!1031!DevInfo,!MDG&database&2010:&Haiti.!Available!at!http://www.devinfo.info/mdginfo2010/!1032!UNICEF,!State&of&the&world’s&children&2009!(Oxford:!Oxford!University!Press,!2009).!Available!at!http://www.unicef.org/sowc/!!


1035!UNICEF,!At&a&glance:&Haiti!(March!2010).!Available!at!http://www.unicef.org/infobycountry/haiti_statistics.html!!




1039!P.!Lawrence,!J.!Meigh,!and!C.!Sullivan,!The&water&poverty&index:&An&international&comparison,!Keele!Economics!Research!Paper!19!(October!2002).!Available!at!http://www`docs.tu`cottbus.de/hydrologie/public/scripte/lawrence_etal2002.pdf!!

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Figure.73:.Access.to.improved.water.source,.by.urban/rural.status,.1990T2006.

!Data!source:!DevInfo,!MDG&database&2010:&Haiti.!Available!at!http://www.devinfo.info/mdginfo2010/!!!In!the!absence!of!accessible!public!utilities,!most!Haitian!households!must!either!purchase!water!from!public!or!private!utilities!or! risk! sickness! from!unprotected!sources.! In!2001,!only!12.6%!of!water!was!accessed!through!private!and!public!infrastructure,!with!access!higher!in!Port`au`Prince!(28.3%)!than!in!other!urban!(16.5%)!or!rural!(7.9%)!areas.1040!Commercial!water!kiosks,!though!expensive,!have!been!a!mainstay! of! water! access,1041,1042,1043! accounting! for! approximately! 30%! of! water! consumption! in! the!metropolitan! area! prior! to! the! earthquake.1044! Also! common! has! been! reliance! on! water! trucked! to!cisterns!and!then!sold!to!end!users.1045!However,!because!these!sources!can!be!either!too!expensive!or!unavailable,!many!households!have!traditionally!collected!water!from!superficial!sources,!such!as!rivers!and!lakes,!which!are!often!highly!contaminated.1046!!









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Clean! water! is! not! cheap! in! Haiti,! and! families! spend! a! significant! proportion! of! their! income! on!commercially! supplied!water.1047! In!2008,!Varma!et&al.&undertook!a! study! in!Port`de`Paix! in! the!NordÒuest! Department! that! found! that! a! family! of! four! would! have! to! spend! approximately! 12%! of! its!average!annual! income!on!water!alone! if!each!person!was!to! receive!the!World!Health!Organization’s!recommended!minimum! of! 20! liters! per! day! for! drinking,! bathing,! etc.! The! authors! note! that! this! is!equivalent! to! “asking! a! U.S.! family! living! at! the! poverty! level! (US$20,444! per! year)! to! pay! nearly!US$2,500!per!year!for!water.”1048!Additionally,!19.2%!of!survey!respondents!stated!that!the!time!taken!to!collect!water! impacted!their!children’s!ability!to!attend!school.!As!a!result!of! the!high!cost!of!clean!water! in! Haiti,! the!World! Bank! has! found! a! strong! association! between! income! and! access! to! clean!water,!especially!in!the!metropolitan!and!other!urban!areas!(Figure!74).1049!!Figure.74:.Access.to.water,.by.income.quintile,.2001.


!!The! provision! of! clean! water! is! a! priority! following! any! disaster.! After! January! 12,! 2010,! Water,!Sanitation!and!Hygiene!(WASH)!Cluster!partners!established!a!substantial!water!distribution!system!to!meet!the!needs!of!the!earthquakeàffected!population.!By!April!19,!2010,!less!than!25%!of!the!Portàu`Prince!population!was! receiving! the!minimum!Sphere!emergency! standard!of!15! liters!per!person!per!day,! with! a! comparable! proportion! lacking! access! in! other! affected! areas.1050! However,! by! July,! 1.2!million! people!were! receiving! at! least! 5! liters! per! day!—! a! transport! volume! of! approximately! 6,200!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1047!Oxfam!America,!Haiti:&A&once5in5a5century&chance&for&change,!Oxfam!Briefing!Paper!136!(March!2010).!Available!at!http://www.oxfamamerica.org/publications/haitiàònceìnà`century`chance`for`change!!




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cubic!meters!–!though!it!is!unclear!how!many!were!receiving!the!Sphere!minimum!standard!of!15!liters!per! day.1051,1052! UNICEF! has! noted! that! water! distribution! reached! a!maximum! of! 8.3!million! liters! to!680,000! people.1053! The! WASH! Cluster! has! begun! disengagement! from! water! delivery! activities,!transitioning!to!system!strengthening! initiatives.1054!However,!as!only!39%!of! IDP!camps!had!access!to!chlorinated!water!points! in!May!2011,! the!provision!of! clean!water! remains! an!urgent!need! in! short`term!relief!programming.1055!!Following! the! earthquake,! several! surveys! indicated! that! Haitians’! source! of! water! in! earthquakeàffected! areas! changed,! although! these! findings! vary.! In! March! 2010,! the! CNSA! found! that! water!collected! from! private! or! public! faucets! increased! from! 29%! to! 41%! of! total! water! consumption,!especially!in!camps!(51%),!while!purchased!water!decreased!from!30%!of!total!water!consumed!to!23%!after! the! earthquake.1056! In! contrast,! an! assessment! conducted! by! World! Vision! in! the! same! month!found! that! 56%!of! respondents! purchased! their!water,!while! another! 30%!were!dependent! on!water!aid.1057! Estimates! by! Kolbe! et& al.& also& suggested! high! rates! of! purchased! water,! finding! that! 75%! of!respondents!in!Portàu`Prince!purchased!their!water!from!a!kiosk,!with!cisterns!filled!by!trucks!the!next!most!common!source.1058!!Since! the! earthquake,! UNICEF! has! prioritized! the! provision! of! clean! water! to! schools,! following! an!assessment!by!the!Education!Ministry!and!Education!Cluster!showing!that!few!schools!had!on`site!water!access.1059!In!July!2010,!UNICEF!reported!reaching!approximately!20,500!children!through!their!work!in!




1054!Government!of!Haiti/ACF,!Strategie&de&desengagement:&Water&trucking!(March!29,!2011).!Available!at!http://www.dinepa.gouv.ht/wash_cluster/index.php?option=com_rokdownloads&view=file&task=download&id=1492%3A201103desengagementwt`dinepaàcfstrategievf&Itemid=67!







!


18!schools,!with!plans! to!expand! into!an!additional!630!schools!by!2011.1060!By! January!2011,!UNICEF!reported!reaching!150!schools!with!comprehensive!water,!sanitation,!and!hygiene!packages.1061!!The! proportion! of! Haiti’s! population! with! access! to! improved! sanitation! facilities! declined! by!approximately! 35%! between! 1990! and! 2006! (Figure! 75).1062! In! 1990,! it! was! estimated! that! 29%! of!Haitians!were!using!improved!sanitation,!with!usage!in!urban!areas!(49%)!almost!2.5!times!higher!than!in! rural! areas! (20%).! By! 2006,! only! 19%! of! Haitians! reportedly! used! improved! sanitation,! with! usage!falling!in!both!urban!(29%)!and!rural!(12%)!zones.1063,1064,1065,1066,1067,1068,1069!More!recent!estimates!have!indicated! that! the! situation!has! continued! to!decline.!By!2008,! the!Millennium!Project!estimated! that!only!17%!of!all!Haitians!used!improved!sanitation!facilities,!with!continued!declines!in!both!urban!(24%)!and! rural! (10%)! areas.1070,1071,1072! Prior! to! the! earthquake,! open! defecation! or! the! use! of! plastic! bags!were! the! most! common! alternatives! to! using! improved! sanitation! facilities.1073,1074! Lack! of! access! to!appropriate!sanitation!facilities!in!both!public!and!private!schools!was!also!a!concern,!given!its!potential!to!dissuade!enrollment.1075!



1062!DevInfo,!MDG&database&2010:&Haiti.!Available!at!http://www.devinfo.info/mdginfo2010/!1063!World!Bank,!World&development&indicator&database.!Available!at!http://databank.worldbank.org/ddp/home.do?Step=12&id=4&CNO=2!

1064!DevInfo,!MDG&database&2010:&Haiti.!Available!at!http://www.devinfo.info/mdginfo2010/!1065!UNICEF,!State&of&the&world’s&children&2009!(Oxford:!Oxford!University!Press,!2009).!Available!at!http://www.unicef.org/sowc/!!




1069!UNICEF,!At&a&glance:&Haiti!(March!2010).!Available!at!http://www.unicef.org/infobycountry/haiti_statistics.html!!



1072!Oxfam!America,!Aid&to&Haiti,&6&months&on:&a&long&way&to&go,!Oxfam!media!briefing!(July!2010).!Available!at!http://www.oxfamamerica.org/publications/aid`to`haiti`6`months`on`a`long`way`to`go/!!





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!Figure.75:.Access.to.improved.sanitation.facilities,.by.urban/rural.status,.1990T2006.

!Data!source:!DevInfo,!MDG&database&2010:&Haiti.!Available!at!http://www.devinfo.info/mdginfo2010/!!!The! risks! associated!with! inadequate! sanitation,! already! significant! before! the! earthquake,!multiplied!substantially! after! January!12,! 2010,! as!more! than!1!million!people!were!displaced!and! infrastructure!destroyed.!Cramped!conditions!in!camps!facilitate!the!spread!of!diseases,!while!endemic!low!sanitation!usage! rates! in! non`camp! communities! continue! to! place! the! population’s! health,! and! especially!children’s!health,!in!a!tenuous!position.1076!The!cholera!outbreak!in!late!2010!is!one!manifestation!of!this!risk,! as! poor! sanitary! conditions! continue! to! allow! the! spread! of! water`borne! intestinal! diseases.!Assessments!conducted! in! the!weeks! following! the!earthquake! found!the!presence!of! feces! in!46%!of!surveyed!sites!near!houses!or! shelters! in!Portàu`Prince,!with!34%!of! these!cases!also!situated!near!a!water! source.1077! Though! sanitation! improved! as! relief! efforts! became!more! established,! inadequate!access!to!and!use!of!sanitation!facilities!continues!to!jeopardize!the!health!of!Haiti’s!children.!!By!the!end!of!February!2010,!two!thirds!of!priority!sites!in!Portàu`Prince!had!some!form!of!sanitation,!including! pit! latrines! (29%),! mobile! toilets! (28%)! and! Ventilated! Improved! Pit! (VIP)! latrines! (9%).! On!average,! there! were! approximately! 411! people! per! latrine,! with! a! range! of! 66.8! –! 941! people! per!latrine.1078!In!non`camp!affected!areas,!22%!of!households!lacked!latrines!of!any!kind,!while!22%!shared!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1076!Oxfam!America,!Haiti:&A&once5in5a5century&chance&for&change,!Oxfam!Briefing!Paper!136!(March!2010).!Available!at!http://www.oxfamamerica.org/publications/haitiàònceìnà`century`chance`for`change!!

1077!CDC,!CDC&summary&of&initial&rapid&assessment&conducted&by&UN&OCHA&in&Haiti!(February!2010).!1078!UN!OCHA!Haiti,!Haiti:&Humanitarian&assessment&key&findings&No.&1,!22!March!2010!(March!2010).!Available!at!http://haiti.cridlac.org/XML/eng/doc90885/doc90885`contenido.pdf!!

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one! latrine!with! three! or!more! families,! 10%!with! one! or! two! other! families,! and! 28%! had! exclusive!access!to!a!latrine.1079!!By! July! 2010,! access! to! sanitation! facilities! had! improved! significantly.! After! six! months! of! relief!operations,! the!WASH! Cluster! had! constructed! 11,000! toilets,! improving! the! average! toilet`to`person!ratio!to!approximately!1:145!and!reaching!roughly!1.6!million!people.1080,1081!An!additional!5,500!toilets!were! planned! for! construction! by! the! end! of! 2010,! providing! one! toilet! for! approximately! every! 100!people.1082! By!May! 2011,! a! survey! by! the!WASH!Cluster! found! that! 94%! of! surveyed! IDP! camps!with!more! than! 1,500! people! had! fewer! than! 100! people! per! latrine.1083! This! proportion! represents! a!significant! improvement!during! the! first! five!months!of! 2011.! Troublingly,! however,! the! survey! found!significant!disparity! in! sanitation!across!Communes,!with!155!people!per! latrine! in! Leogane!versus!36!people!per!latrine!in!Croix`Des`Bouquets!(Figure!76).1084!!





1083!Haiti!WASH!Cluster,!Enquete&WASH&dans&les&Sites&d’hebergement&temporaire!(May!2011).!Available!at!http://www.dinepa.gouv.ht/wash_cluster/index.php?option=com_rokdownloads&view=file&Itemid=57&id=1468:110616`enquete`wash`site`hebergement`temporaire!!


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Figure.76:.Number.of.people.per.latrine.and.shower.in.assessed.camps,.by.Department,.May.2011.

!Source:!UN!OCHA,!Humanitarian&bulletin:&1&July&–&25&July&2011!(July!2011).!Available!at!http://haiti.humanitarianresponse.info/LinkClick.aspx?link=Nutrition+Cluster%2f1_Juillet_25Juillet2011_Haiti_Humanitarian_Bulletin.pdf&tabid=80&mid=1033!!

!!UNICEF!was!also!working!with!partner!organizations!to!implement!hygiene!promotion!and!infrastructure!construction! programs! in! schools! across! Haiti,! facilitating! school! access! and! empowering! children!outside!of!the!camp!environment.1085!However,!across!IDP!camps!surveyed!by!the!WASH!Cluster!in!May!2011,! only! 18%! had! functioning! hand! washing! stations! in! May/June;! a! decrease! from! 20%! in! April!2011.1086!While!improved!access!to!latrines!is!an!impressive!achievement,!especially!given!the!impact!of!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1085!UNICEF,!Children&of&Haiti:&Milestones&and&looking&forward&at&six&months!(July!2010).!Available!at!http://www.unicef.org/emerg/files/UNICEF_Haiti_`_Six_Months_Report_Final.pdf!!


!


the!intervention!on!reducing!the!spread!of!cholera!and!other!diseases,!inadequate!access!to!clean!water!and!hygiene!remain!significant!concerns!for!the!holistic!protection!of!Haiti’s!children.!!!

D.&Shelter&and&housing&!Prior! to! the! 2010! earthquake,!many!Haitians! reported! difficulties! accessing! quality! affordable! shelter!and!housing.!A! survey!conducted! in!2008! found! that!51%!believed! they! lacked!sufficient! resources! to!provide!adequate!shelter!for!their!families!in!the!preceding!year.1087!In!2009,!2.3%!of!the!population!in!Port`au`Prince! reported! that! finding!housing!was!a! serious!problem.!This!proportion! jumped! to!100%!immediately! following! the! earthquake.1088! Shortage! of! construction! materials,! including! timber,! and!increased!input!costs!have!been!cited!as!barriers!to!appropriate!housing.1089!!Land!tenure!was!a!significant!problem!facing!Haitians!both!before!and!after!the!earthquake.!Almost!75%!of! land! tenure! is! informal,1090! and! Haiti! has! not! completed! a! land! holdings! survey! in!more! than! 200!years.1091! Lack! of! formal! land! documentation! in! public! registries,! reliance! on! oral! contracts! for! land!ownership,! and!chaotic!duplicate! systems!have!produced!a! situation! in!which!official! land!boundaries!are!not!known,!resulting!in!multiple!competing!ownership!claims!that!may!be!equally!valid!for!one!piece!of! land.! The! use! of! Napoleonic! law! for! Haiti’s! land! title! system! means! that! each! descendant! of! a!deceased! landowner! is! equally! entitled! to! the! land,! so! that! in!many! cases! the! competing! interests! of!dependents!prevents!resolution!of!land!claims.!This!situation!results!in!ever`shrinking!plots!of!land!with!each! successive! generation,! even!when! a! satisfactory! agreement! is! achieved.1092!While! there! is! some!debate! about! the! importance! of! formal! land! title! in! Haiti,! some! residents! have! expressed! their!unwillingness! to! invest! in! improvements! due! to! uncertainty! of! their! legitimate! ownership.1093! The!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1087!S.!Crabtree,!J.!Godoy,!and!J.!Ray,!Survey&highlights&Haitians’&vulnerability:&Access&to&food,&shelter,&healthcare&less&prevalent&than&in&neighboring&countries,!Gallup!(January!2010).!Available!at!http://www.gallup.com/poll/125075/survey`highlights`haitians`vulnerability.aspx!!








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January!2010!earthquake!exacerbated!these!concerns,!as!lack!of!formal!title!and!competing!claims!have!confounded!efforts!to!remove!debris!and!begin!reconstruction!when!ownership!is!unclear.1094!!The!vast!majority!of!Haitians!do!not!own!either!the!land!or!house!in!which!they!live.!In!rural!areas,!large!landowners!(known!as!grandons)!operate!their!large!tracts!of!land!on!a!sharecropping!system.!In!these!cases,! owners! allow! tenants! to! live! on! and! work! the! land! in! exchange! for! a! percentage! of! goods!produced.1095!In!urban!areas,!the!International!Federation!of!Red!Cross!and!Red!Crescent!Societies!(IFRC)!reports!that!between!60`80%!of!residents!rent!either!their!house!or!the!land!the!house!stands!on,!and!rent!is!paid!for!six!months!to!one!year!in!advance.1096!The!Haitian!state!and!the!Catholic!Church!together!own! approximately! 70%! of! all! urban! land,! with! only! the! remaining! 30%! owned! by! individuals! or! the!private! sector.! It! is! believed! that! the! majority! of! private! land! in! Haiti! is! owned! by! fewer! than! 20!families.1097!!Analysis! conducted! as! part! of! Phase! 1! of! the! Camp! Coordination! and! Camp! Management! Cluster’s!(CCCM)! registration!process! found! that! 60%!of! registered! IDPs!were! tenants!prior! to! the!earthquake,!with!64%!of!households!in!Port`au`Prince!and!42%!of!those!in!southern!Departments!renting!their!pre`earthquake!accommodations.1098!While! the! total! number!of! registered! IDP!households!had!decreased!significantly!by!CCCM’s!June!2011!report!on!Phase!2!registration,!the!proportion!of!those!registered!who!were! tenants! prior! to! the! earthquake! had! increased! to! 78%.! This! increase! supports! responders’!hypothesis!that!those!who!were!renting!prior!to!the!earthquake!would!have!greater!difficulty!identifying!viable!and!sustainable!housing!solutions!outside!of!IDP!camps.1099!!Prohibitive! cost,! low!ownership! rates,! and! the!absence!of!building! code!enforcement!meant! that! less!than!15%!of!building!construction!before!the!earthquake!involved!a!design!professional.1100!The!lack!of!feasibility!assessment,!poor!construction!work,!and!the!use!of!low!quality!construction!materials!played!a! significant! role! in! the! degree! of! devastation! caused! by! the! earthquake,! which! rendered!disproportionate!damage!relative!to!its!magnitude.!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1094!IFRC,!Haiti&recovery&assessment:&Volume&1&–&Synthesis&report!(March!2010).!Available!at!http://haiti.humanitarianresponse.info/LinkClick.aspx?fileticket=jNS41RGePVg%3d&tabid=149&mid=1043!!




1098!Haiti!CCCM!Cluster,!Registration&of&internally&displaced&populations&affected&by&the&earthquake&in&Haiti!(December!2010).!Available!at!http://www.eshelter`cccmhaiti.info/pdf/phase_1_registration_final_report_dec_21.pdf!!

1099!Haiti!CCCM!Cluster,!Registration&update:&Phase&2!(June!2011).!Available!at!http://www.eshelter`cccmhaiti.info/pdf/REGISTRATION_UPDATE_Phase_2_Mid_Year_Report_June_2011ENGLISH_FINAL%20_Revised.pdf!


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Of!particular!importance!to!the!degree!of!damage!experienced!on!January!12,!2010!was!the!proportion!of! the!population! living! in! slums! in!affected!areas.!Persistent!urbanization! to!Portàu`Prince!above! its!absorptive!capacity!(discussed!in!Section!3A.&Urbanization)!prohibited!monitoring!and!service!provision.!Slums!often!developed!on!the!least!suitable,!and!most!risky,!parts!of!land,!including!on!steep!slopes!or!in! gullies! and! valleys.! These! vulnerabilities—compounded! by! the! use! of! poor! quality! construction!materials!and!overcrowding,!heightened!the!risk!of!flooding,!landslides,!exposure!to!epidemic!diseases,!and! building! collapses—were! underscored! by! the! disastrous! impact! of! the! earthquake.! A! 1997! study!found! that! 67%!of! the! urban! population! lived! in! slums,!which! accounted! for! only! 22%!of! inhabitable!land.1101! In! 2001,! Dash! noted! the! extreme! crowding! in! the! Portàu`Prince! slum! district! of! Cite! Soleil,!where! 400,000! people!were! packed! into! districts!with! little! access! to!water! or! sanitation,! faced!with!chronic!flooding!during!the!rainy!seasons,!and!population!density!such!that!at!least!four!adults!sleep!in!a!single!bed! in!shifts,!while!other!household!members!spent! their! time! in! the!neighborhood!due! to! the!lack!of!space!at!home.1102!!The! January! 2010! earthquake! damaged! or! destroyed! a! very! high! percentage! of! houses! in! Haiti,!highlighting!their!structural!vulnerability.!While!estimates!of!the!extent!of!the!damage!differ!by!source,!all! present! a! bleak! picture! for! the! shelter! needs! of! Haitian! children! and! their! families.! In! their! Post`Disaster! Needs! Assessment,! the! Haitian! Government! stated! that! approximately! 105,000! homes!were!completely! destroyed,! while! a! further! 208,000! were! significantly! damaged,! meaning! that! 71.6%! of!former! residents! could!no! longer! live! in! their! former!homes.1103!The!University!of!Michigan!and!Small!Arms!Survey!found!that!only!34.7%!of!all!metropolitan!area!residents!and!3.2%!of! IDP!camp!residents!had!suffered!no!visible!damage!to!their!homes.1104!The!CNSA!rapid!emergency!food!assessment!found!that! 30%! of! respondents! in! Portàu`Prince,! including! Delmas,! Croix`des`Bouquets,! Grand! Goâve,! and!Carrefour,! thought! that! their! house! was! destroyed! or! uninhabitable,! as! did! 50%! of! respondents! in!Gressier,! Léogâne,! and! other! urban! and! rural! earthquakeàffected! areas.1105! These! estimates! are!significantly! lower! than! those! found! by! U.S.!military! engineers,! who! estimated! that! up! to! 80`90%! of!buildings! in! Léogâne! and! 60`70%! of! those! in! districts! in! Portàu`Prince! were! destroyed! or! unfit! for!habitation.1106!


1102!J.!M.!Dash,!Culture&and&customs&of&Haiti!(Westport,!CT:!Greenwood!Press,!2001).!1103!Government!of!Haiti,!Haiti&earthquake&PDNA:&Assessment&of&damage,&losses,&general&and&sectoral&needs!(March!2010).!Available!at!http://siteresources.worldbank.org/INTLAC/Resources/PDNA_Haiti`2010_Working_Document_EN.pdf!




1106!Cited!in!IFRC,!Haiti&recovery&assessment:&Volume&1&–&Synthesis&report!(March!2010).!Available!at!http://haiti.humanitarianresponse.info/LinkClick.aspx?fileticket=jNS41RGePVg%3d&tabid=149&mid=1043!!

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!The! Haitian! Government! estimated! in!March! 2010! that! approximately! 1.3!million! people!were!made!homeless!by!the!earthquake.1107,1108!Estimates!by!UNICEF!in!June!were!higher,!at!1.6!million!people,!of!which!800,000!(50%)!were!thought!to!be!children.1109!Both!estimates!were!surpassed!by!the!findings!of!World!Vision,!which,!after!surveying!Portàu`Prince!and! its!other!operational!areas,! found!that!76%!of!those!in!earthquakeàffected!areas!were!displaced1110—a!finding!closer!to!what!would!be!expected!from!extrapolations!of!building!damage!assessment!by!the!U.S.!Army!Corps!of!Engineers.!!Analysis! conducted! for! the! CNSA! rapid! emergency! food! assessment! found! that,! as! expected,! the!probability!of!an!individual’s!living!either!full`time!or!part`time!in!a!camp!increased!with!the!degree!of!household! destruction,!while! the! probability! of! living!with! a! host! family! remained! relatively! constant!across!house!damage!categories!(Figure!77).1111!Those!whose!former!residence!was!either!destroyed!or!needed!to!be!demolished!were!more!likely!to!spend!at!least!some!of!their!time!in!camps!(approximately!73%!and!66%,!respectively)!compared!to!those!whose!residence!was!unaffected!(approximately!22%)!or!could! be! repaired! (approximately! 37%).! Notably,! a! significant!minority! of! respondents! whose! homes!were! either! destroyed! or! required! demolition!were! still! living! in! or! beside! their! former! residence.1112!This!is!consistent!with!estimates!by!World!Vision,!which!found!that!the!vast!majority!of!families!in!their!operational! areas! outside! of! Portàu`Prince! were! living! either! in! or! beside! their! houses,! while! many!other! respondents!had!migrated! to! the!homes!of! friends! and! families! in! search!of! safer! lodgings! and!employment.1113!!




1110!Cited!in!UN!OCHA!Haiti,!Haiti:&Humanitarian&assessment&key&findings&No.&2,!29!March!2010!(March!2010).!Available!at!http://groups.google.com/group/assessmentshaiti/browse_thread/thread/71f3f127213f7a06!!




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Figure.77:.Current.place.of.residence,.by.status.of.preTearthquake.residence,.March.2010.


!!By! June! 7,! 2010,! the! Camp! Coordination! and! Camp! Management! Cluster! (CCCM)! for! the! Haiti!earthquake! response! had! identified! 1,342! IDP! camps! in! earthquakeàffected! areas,! consisting! of!approximately!380,000!households!and!a!total!population!of!1.6!million.!Of!those!households,!52%!were!located! in! Portàu`Prince,! Carrefour,! and!Delmas,! roughly! equivalent! to! the!distribution!of! IDP! camps!across!affected!areas!(Figure!78).!In!total,!28.12%!of!individuals!living!in!IDPs!were!living!in!camps!with!more!than!1,000!households,!while!65.74%!were!estimated!to!be!living!in!camps!with!between!100!to!1,000!households,!and!6.09%!of!individuals!living!in!camps!of!fewer!than!100!households.!Although!only!3.71%!of! camps!were! composed! of!more! than! 1,000! households,! they! accounted! for! over! 28%!of! all!individuals!living!in!camps.1114!Overall,! it!was!found!that!66.64%!of!households!living!in!camps!of!more!than! 1,000! households! were! serviced! by! a! camp!management! agency,! with! significant! discrepancies!between!camps!in!Delmas,!Petion`Ville,!and!Portàu`Prince,!which!experienced!nearùniversal!coverage,!while!Carrefour,!Cite!Soleil,!Croix`des`Bouquets,!and!Tabarre!had!an!average!coverage!of!27.6%.1115!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1114!IOM,!Displacement&tracking&matrix:&Summary&of&IDP&situation,!Haiti!CCCM!Cluster!(June!2010).!1115!IOM,!Displacement&tracking&matrix:&Summary&of&IDP&situation,!Haiti!CCCM!Cluster!(June!2010).!

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Figure.78:.Distribution.of.IDP.camps.and.households.by.commune,.June.2010.

!Source:!IOM,!Displacement&tracking&matrix:&Summary&of&IDP&situation,!Haiti!CCCM!Cluster!(June!2010).!!!By!September!2011,!the!number!of!individuals!and!families!living!in!IDP!camps!had!fallen!markedly.!The!Displacement!Tracking!Matrix,!compiled!by!the!CCCM!Cluster,!found!that!by!the!end!of!September!2011,!the!number!of!camps!in!earthquake`affected!areas!had!fallen!to!802,!consisting!of!135,961!households!and!550,560! individuals.!This! finding!suggests!that!the!total!number!of!people! living! in! IDP!camps!had!fallen! by! 64%! compared! to! July! 2010! (Figure! 79).! 95%! of! these! 802! remaining! IDP! camps! had! been!established!within!two!months!following!the!earthquake.! Interestingly,!the!number!of!households!and!individuals!living!in!IDP!camps!has!fallen!faster!than!the!reduction!in!the!number!of!camps.1116!!Figure.79:.Number.of.IDP.sites,.households,.and.individuals,.July.2010TSeptember.2011.

!Source:!IOM,!Displacement&tracking&matrix:&V2.0&update,!Haiti!CCCM!Cluster!(September!2011).!Available!at!http://www.cccmhaiti.info/pdf/DTM_V2_Report_September_English.pdf!!

!!After!six!months!of!relief!operations,!the!UN!reported!that!their!distribution!of!emergency!shelter!items!had! surpassed! estimates! of! the! affected! population,! with! approximately! 100,000! people! per! week!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1116!IOM,!Displacement&tracking&matrix:&V2.0&update,!Haiti!CCCM!Cluster!(September!2011).!Available!at!http://www.cccmhaiti.info/pdf/DTM_V2_Report_September_English.pdf!!

HHAAIITTII CCaammpp CCoooorrddiinnaattiioonn CCaammpp MMaannaaggeemmeenntt CClluusstteerr

3� DTM�v2.0�Update�–�JulyͲSeptember�2011�

Table A: Number of IDP Sites, Households and Individuals identified through DTM – Total by Month July 2010 to September 2011

Month Sites Households Individuals

JUL '10 1,555 361,517 1,536,447SEP '10 1,356 321,208 1,374,273NOV '10 1,199 245,586 1,068,882JAN '11 1,152 195,776 806,377MAR '11 1,152 171,307 680,494MAY '11 1,061 158,437 634,807JUL '11 894 149,317 594,811SEP '11 802 135,961 550,560

Graphs: Number of IDP Sites (Graph 2), Households (Graph 3), and Individuals (Graph 4), identified through DTM – Total by Month July 2010 to September 2011 Graph 2 Graph 3 Graph 4

METHODOLOGY

IOM rolled out DTM V2.0 in October 2010. This rapid camp-based assessment is implemented by a team of 191 staff, of which 82 are field staff that carryout the data gathering activities. During a bi-monthly DTM cycle, assessments of all identified IDP sites are conducted within a six week period which includes all activities, namely, data collection, verification, data-processing and analysis. The DTM field teams use the DTM v2.0 - IDP Site/Camp Information form for each assessment. The teams use various methods, including key respondent interviews with camp managers and camp committees and observation and physical counting in order to collect all data to complete the form. The field teams approach each individual IDP site in a targeted manner, meaning that the method of data collection can vary depending on the situation of that specific IDP site. After the data is gathered, consultation is carried out with actors that have a regular presence on the ground, namely, IOM Camp Management Operations (CMO) teams, representatives from the DPC, and other service providers. The IOM Data Management Unit’s call centre is also employed to verify data directly with IDP Camp Committees or other relevant respondents. Google Earth and other available technology can also assist in determining a variety of data, such as location and area. More details on DTM methodology are available on the CCCM cluster website. The DTM v2.0 Assessment Form gathers more concise information than the previous DTM v1.0, narrowing the focus and providing basic information on IDP sites and IDP populations for the benefit of humanitarian actors carrying out intervention in the earthquake affected areas across the country.

Sites

1,5551,356

1,199 1,152 1,152 1,061894 802

JUL '10

SEP'10

NOV'10

JAN '11

MAR'11

MAY'11

JUL'11

SEP'11

Households

361,517321,208

245,586195,776

135,961171,307158,437

149,317

JUL '10

SEP'10

NOV'10

JAN '11

MAR'11

MAY'11

JUL '11 SEP'11

Individuals

1,536,4471,374,273

1,068,882

680,494550,560

806,377

634,807

594,811

JUL '10

SEP'10

NOV'10

JAN '11

MAR'11

MAY'11

JUL'11

SEP'11

!


benefiting! from!shelter!distributions! in! the! first! four!months!of! the! response.1117!While! some! form!of!shelter! distribution! may! have! reached! all! affected! populations,! these! distributions! may! not! have!provided! sufficient! long`term! protection,! especially! in! the! face! of! hazards! posed! by! the! 2010`2011!hurricane!season.!By!the!end!of!April,!Schiff!et&al.!found!that!almost!100%!of!respondents!in!Les!Cayes,!Gonaïves,!and!Jeremie!were!living!in!a!building!or!shelter!with!an!iron!roof.!However,!only!7%!of!the!IDP!population!in!Port`au`Prince!was!living!in!similar!buildings,!with!90%!living!under!a!tarp!or!in!a!tent!and!3%! reporting! a! lack! of! shelter! of! any! kind.! Schiff! noted! that! overall,! 99%! of! IDPs! had! access! to! a!waterproof!roof!by!April!19,!2010,!and!found!a!significant!association!between!residence!in!a!camp!with!a!camp!manager!and!access!to!waterproof!shelters.1118!!Based!on!estimates!by!the!Displacement!Tracking!Matrix,!in!2011!the!Haiti!Shelter!Cluster!determined!a!need!of!approximately!138,269!temporary!and!permanent!shelters.!In!March!2011,!the!Cluster!reported!the!completion!of!56,743! transitional! shelters,!with!a! further!59,696!planned.1119!By!August!2011,! the!number!of!completed!transitional!shelters!had!increased!to!94,879,!or!83.7%!of!all!planned!transitional!shelters—remarkable! progress! given! the! continued! challenges! facing! relief! operations! in! Haiti.1120! In!addition,! the! Cluster! reported! completion! of! 4,596! permanent! shelters,! or! 37.4%! of! the! 12,281!planned.1121!!!

E.&Information&and&communication&technology&!Since! the! turn! of! the!millennium,!Haiti! has! seen! a! rapid! diffusion! of! information! and! communication!technologies!(ICT),!providing!new!avenues!for!relief!and!development!through!the!rapid!collection!and!distribution! of! information! to! organizations! and! individuals.! Following! the! earthquake,! technologies!were! used! to! assess! population! movement! (such! as! in! the! analysis! conducted! by! Digicell),! collect!information!to!assist!in!targeting!relief!operations!(such!as!that!conducted!by!Ushahidi),!and!disseminate!information! via! text! messages! to! individuals! regarding! available! services.! However,! despite! recent!increases! in! coverage! of! ICT! in! Haiti,! many! segments! of! the! population! remained! without! access! to!information!on!the!eve!of!the!earthquake.!!



1119!Haiti!Shelter!Cluster,!Shelter&cluster&needs&and&gaps&analysis!(March!2011).!Available!at!https://sites.google.com/site/shelterhaiti2010/files/SHELTER_NEED_ANALYSIS_march_2011_final3.pdf?attredirects=0!!

1120!Haiti!Shelter!Cluster,!Shelter&cluster&shelter&completion&update!(August!2011).!Available!at!https://sites.google.com/site/shelterhaiti2010/files/110831Summaryreportbycommune.pdf?attredirects=0!!

1121!Haiti!Shelter!Cluster,!Shelter&cluster&shelter&completion&update!(August!2011).!Available!at!https://sites.google.com/site/shelterhaiti2010/files/110831Summaryreportbycommune.pdf?attredirects=0!!

&



Underlying!many! individuals’! lack! of! access! to! ICT! is! poor! electricity! coverage! across! Haiti.! The!most!recent!estimate!of! coverage!Haiti`wide! is!derived! from!the!2001!Haiti! Living!Conditions!Survey,!which!showed! that!only!23.9%!of!Haitians!households!had!electricity.! Significant!disparities!existed!between!urban! (22.5%),! rural! (9.8%),! and! the! metropolitan! Portàu`Prince! (91.4%)! areas,! as! well! as! by! socioèconomic!status!(Figure!80).1122!By!2009,!the!proportion!of!metropolitan!residents!reporting!household!electrification!had!decreased! to! 88%.! The! earthquake! severely! damaged! the! electricity! infrastructure,!such! that! 87%! of! metropolitan! area! respondents! reported! lacking! household! electrification! in!February/March!2010.1123!On!July!26,!2011,!the!InterÀmerican!Development!Bank!reported!that!70%!of!all!Haitians! lacked!access! to!electricity! and! that! those!areas!with! coverage! received!electrification! for!only! ten! hours! per! day.! However,! 2011! saw! the! InterÀmerican! Development! Bank! grant! the! state!electricity!company,!Eléctricité!d’Haïti,!approximately!$35!million!to!modernize! the!sector!and!expand!coverage,!raising!hopes!of!greatly!expanded!access!in!the!medium`term.1124 !Figure.80:.Access.to.electricity.(%),.by.urban/rural/metropolitan.area.status.and.income.quintile,.2001.


The! six`year!period! from!2002`2008,! and!especially! the!period!2005`2008,! saw!a!dramatic! increase! in!the!proportion!of!Haitians!with! telephone!communications! (Figure!81).! In!1998,!only!0.9%!of!Haitians!had! access! to! any! kind! of! phone! service.! By! 2009,! this! proportion! had! increased! to! 38.1%,! of! which!



1124!Inter!American!Development!Bank,!IDB&makes&$35&million&grant&for&Haiti’s&electricity&sector!(July!2011).!Available!at!http://www.iadb.org/en/news/news`releases/2011`07`26/support`forènergy`reformìn`haiti,9475.html!!

!


97.0%!were!mobile! phone! subscriptions.1125! Smucker,! Pierre,! and! Tardieu! attributed! the! rapid! rise! in!mobile!phone!subscriptions!to!intensive!marketing!efforts!by!phone!companies!in!poor!communities.1126!Though! World! Bank! data! is! unavailable! for! 2010! and! 2011,! it! is! likely! that! the! proportion! of! the!population!with!access!to!phone!services!continued!to!increase,!although!it!is!unclear!what!impact!the!earthquake!has!had!on!mobile!phone!subscriptions.!Interestingly,!the!Word!Bank!data!from!2009!found!that! a! higher! percentage! of!Haitians! reported! owning! a!mobile! phone! than! having! electricity! in! their!households,!indicating!either!sharing!of!electricity!or!use!of!communal!points!to!charge!phones.!!Figure.81:.Total.and.mobile.phone.subscribers.(%),.1998T2009.

!Date!source:!World!Bank,!World&development&indicator&database.!Available!at!http://databank.worldbank.org/ddp/home.do?Step=12&id=4&CNO=2!

!!The!proportion!of!the!population!using!the!internet!has!substantially! increased!since!2001,!rising!from!0.3%!in!2001!to!10.1%!in!2009!(Figure!82).1127!Reliable!data!on!personal!computer!ownership!in!Haiti!are!sparse,! although! the!World! Bank! estimates! that! in! 2007! there!were! 5.1! personal! computers! per! 100!Haitians.1128!The!discrepancy!between!the!proportion!of!Haitians!using!the!internet!and!the!prevalence!of! personal! computers! again! suggests! sharing! of! ICT! resources,! either!within! or! between! families,! or!widespread!use!of!internet!cafes.!!





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Figure.82:.Internet.users.(%),.1998T2009.


!!Other! forms! of! ICT! used! in! Haiti! include! radio! and! television,! for! which! ownership! estimates! are!outdated.!The!most!recent!national!estimate!of!radio!ownership!is!a!1997!finding!that!5.3%!of!Haitians!had! a! radio.1129! It! should! be! noted! that! following! the! 2010! earthquake,! the! US! armed! forces! and! a!number! of! NGOs! distributed! radios! to! the! earthquakeàffected! population.! However,! it! is! unclear! to!what!degree!these!actions!affected!national!ownership!rates.!The!World!Bank!estimated!that!25.3%!of!households! owned! a! television! in! 2006.1130! It! is! likely! that! this! percentage! has! decreased! significantly!due! to! the! earthquake,! as! ownership!was! concentrated! in! the! Portàu`Prince!metropolitan! area,! and!building!damage!and!collapse!is!likely!to!have!affected!television!access.!!!

F:&Political&and&civic&engagement&!Haitian!society!is!characterized!by!strong!familial!bonds!but!very!low!levels!of!faith!in!public!institutions!and!business.!Family!and!patronage!networks!form!the!foundation!for!the!nonàgricultural!work!sectors,!migration!within!and!from!Haiti!are!generally!facilitated!by!family!members!or!friends,!and!the!majority!(61%)!of!youth!aged!15`24!believe!that!they!have!family!or! friends!that!they!can!count!on! in!times!of!crisis.1131!However,!strong!social!cohesion!does!not!extend!far!beyond!relatives!and!contact!networks.!Of!all! institutions,! youth! in! 2010! had! the!most! confidence! in! the! local! police! (49%! had! confidence)! and!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1129!UNICEF,!State&of&the&world’s&children&2003!(Oxford:!Oxford!University!Press,!2003).!Available!at!http://www.unicef.org/sowc/!!


1131!Gallup!Inc.,!Gallup&worldview&database:&Haiti.!Available!at!https://worldview.gallup.com/default.aspx!

!


religious!organizations!(61%!had!confidence)–low!levels!given!that!these!two!institutions!are!the!most!trusted! in!Haiti.! In! contrast,! youth! had! far! less! confidence! in! the! national! government! (18%)! and! the!judiciary! (19%).! Furthermore,! confidence! in! government! is! unlikely! to! improve! over! the! short`term,!given!that!only!20%!of!youth!believe!that!elections!are!honest.1132!!Low! faith! in! public! institutions! presents! a! challenge! for! child! protection! on! a! number! of! fronts.!Principally,! low!faith!in!the!justice!system,!and!to!a!lesser!degree!in!the!police!force,!leads!to!impunity!for!those!violating!the!rights!of!children,!as!victims!and!their!caregivers!are!unwilling!to!come!forward!to!report! abuses.1133! A! 2009! study! by! Smucker,! Pierre,! and! Tardieu! for! the! Pan`American! Development!Foundation! found!that!only!38%!of!households!with!victims!of!violence! filed!complaints!of! the!abuse.!Households!who!had!filed!a!complaint!were!far!more!likely!to!do!so!at!a!police!station!(approximately!80%)!than!in!the!justice!system!(50`60%),!while!both!the!police!and!the!justice!system!were!more!likely!to! receive! complaints! than! were! human! rights! organizations! (approximately! 20%)! or! women’s!organizations!(approximately!10%)!(Figure!83).1134!Smucker!et&al.!note!that!the!higher!rates!of! filing!at!police!stations!and!the! justice!department!may!be!the!result!of!police!and! justice!departments!having!better!national!coverage!than!human!rights!organizations!and!women’s!organizations:! the!“police!and!the! courts,! though!woefully! inadequate,! are! generally!more! available! than! other! central! government!institutions!in!Haiti.”1135!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1132!Gallup!Inc.,!Gallup&worldview&database:&Haiti.!Available!at!https://worldview.gallup.com/default.aspx!1133!UN!GA,!Report!of!the!special!rapporteur!on!contemporary!forms!of!slavery,!including!its!causes!and!consequences,!Gulnara!Shahinian,!UN!Doc.!A/HRC/12/21/Add.1!(2009).!Available!at!http://www.unhcr.org/refworld/docid/4ac0c6b42.html!



&



Figure.83:.Institutions.where.households.have.filed.complaints,.2009.


!!Lack! of! confidence! in! the! state! and! its! representatives! also! undermines! the! potential! for! democratic!participation! and! the! formulation! of! laws! and! policies! that! protect! and! foster! the! development! of!children.! Voter! turnout! in! Haiti’s! 2006! legislative! elections! amounted! to! less! than! 1/3! of! the! eligible!population,! at! 28.3%.1136! Data! for! the! 2011! national! elections! are! unavailable! at! the! time! of! writing,!although! the!Organization!of!American!States!and!Caribbean!Community!estimated! low!voter! turnout!(approximately! 30%)! in! the! second! round! run`off! of! the! presidential! election.1137! The! population’s!contact! with! non`justice! public! officials! is! similarly! low,! reflecting! underlying! discontent! with! state!institutions! and! representatives.!Of! survey! respondents! in! 2009,! only! 3%!had! come! into! contact!with!mayors!and!other! local!and!Department`level!representatives,!while!only!1%!had!been!in!contact!with!national!parliamentarians,!and!only!2%!had!contacted!ministries!or! state!offices.1138!However,!contact!rates! between! the! population! and! public! officials! appear! to! have! increased! in! the! aftermath! of!earthquake,! with! a! Gallup! Inc.! poll! finding! that! 22%! of! the! population! aged! 15`24! had! voiced! their!opinion!to!a!public!official!in!2010.1139!In!the!wake!of!the!2010!earthquake,!the!vast!majority!of!surveyed!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1136!Institute!for!Democracy!and!Electoral!Assistance,!Voter&turnout&database:&Haiti!(2011).!Available!at!http://www.idea.int/vt/country_view.cfm?CountryCode=HT!

1137!R.!C.!Archibold,!"New!Haitian!leader!pledges!reconciliation,"!New&York&Times!(April!5,!2011).!Available!at!http://www.nytimes.com/2011/04/06/world/americas/06haiti.html!


1139!Gallup!Inc.,!Gallup&worldview&database:&Haiti.!Available!at!https://worldview.gallup.com/default.aspx!

0%!10%!20%!30%!40%!50%!60%!70%!80%!90%!

Police! Justice! Human rights organizations!

Women’s organizations!

!


Haitians! felt! that! the!government!was!not!responsive!to!their!opinions.!Only!12.5%!of!people!thought!that!the!government!cared!about!their!perspective.1140!!The! observed! low! levels! of! confidence! in! public! institutions! stem! from! a! perceived! pervasive! lack! of!fairness! and! accessibility.1141! Foremost! among! these! concerns! is! the! hold! of! corruption! over!independent!decision`making.! In!2010,!62%!of! surveyed!youth! said! they!believed! that! corruption!was!widespread! in! business,! while! an! overwhelming! 72%! believed! the! same! to! be! true! in! the!government.1142! Similarly,! corruption! is! perceived! to! have! permeated! the! justice! system,! such! that!decisions! are! skewed! to! favor! the! rich,! city`dwellers,! and! those! who! are! willing! to! pay! an! “informal!fee”.1143,1144! In! 2005,! Haiti! ranked! 155! out! of! 158! countries! surveyed! in! Transparency! International’s!Corruption!Perception!Index.1145!Since!then,!corruption!perception!has!further!worsened,!from!an!index!score! of! 163! in! 2006,! to! 177! in! 2007,1146! while! Haiti’s! position! on! Transparency! International’s!Corruption! Perception! Index! improved! to! 146! of! 178! countries.! The! World! Bank! has! noted! that!corruption!allegations!target!almost!all!facets!of!public!expenditure;!“embezzlement!of!public!funds!by!political!and!private!organizations;!payments!to!government`associated!individuals!for!goods!that!were!not! provided! and! services! that! were! not! rendered;! abuse! of! discretionary! accounts! by! government!officials;! and! evasion! of! the! licensing! fees! and! import! tariffs! collected! by! public! enterprises”! are! but!some! of! the! alleged! charges! of! corruption! throughout! Haiti.1147! Post`earthquake,! perceptions! of!corruption!persist,!with!77.3%!of!respondents!to!the!February`March!2010!University!of!Michigan!and!Small!Arms!Survey!believing! that!paying!an! “informal! fee”!would! result! in!better! service.1148!Both! the!perception! and! act! of! corruption! undermine! effective! functioning! of! public! and! private! institutions,!discouraging! the! victims! of! rights! abuses! to! come! forward,! stifling! economic! and! educational!opportunities,!especially!for!poor!and!rural!households,!and!deterring!children!and!young!people!from!engaging!with!civic!and!political!life.!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1140!UN!OCHA!Haiti,!Haiti:&Humanitarian&assessment&key&findings&No.&3,!5!April!2010!(April!2010).!Available!at!http://groups.google.com/group/assessmentshaiti/browse_thread/thread/71f3f127213f7a06!!


1142!Gallup!Inc.,!Gallup&worldview&database:&Haiti.!Available!at!https://worldview.gallup.com/default.aspx!1143!UN!ESC,!Situation!of!human!rights!in!Haiti,!UN!Doc.!E/CN.4/2001/106!(2001).!Available!at!http://ap.ohchr.org/documents/dpage_e.aspx?m=47!






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Despite!the!widespread!distrust!of!state!institutions!exhibited!by!Haitians,!the!World!Bank!has!asserted!that!those!most!disenfranchised!by!the!prevailing!system,!those! in!rural!areas,!approve!of!the!current!state!of!affairs!more!than!those!living!in!urban!areas,!potentially!because!approval!statistics!depend!on!expectations! of! the! institutions.! As! such,! approval! of! parliament,! popular! organizations,! and! political!parties!is!positively!correlated!with!distance!from!those!institutions,!with!twice!the!proportion!of!those!in!rural!areas!approving!of!these!institutions!as!those!in!the!metropolitan!area.1149!This!higher!approval!occurs!despite!the!fact!that!the!use!of!French!as!the!official!government!language!has!acted!as!a!“social!filter”!in!Haiti!and!restricted!access!to!state!institutions,!including!political,!economic,!and!social!spaces,!and! that! those! in! rural! areas! are! less! likely! to! speak! French! (20%)! than! their! urban! counterparts!(53%).1150!!The! sense!of! alienation! from!public! institutions! felt! by!Haiti’s!population!has! led! to!engagement!with!other,!more!direct!avenues!for!civic!participation.!In!2010,!91%!of!Haitian!youth!stated!that!religion!was!an! important!part!of!their!daily! lives,!while!88%!reported!that!they!had!attended!a!religious!service! in!the! past! seven! days.1151! In! 2009,! more! than! 40%! of! survey! respondents! in! Portàu`Prince! (40%),!Gonaïves!(45%),!Saint`Marc!(45%)!and!Petit`Goave!(43%)!were!part!of!a!parent`teacher!association,!with!a!lower!proportion!in!Cap`Haitien!(34%).1152!While!participation!was!significantly!lower,!many!Haitians!in!these!five!cities!were!also!active!in!neighborhood!associations,!with!participation!rates!of!9%!in!Portàu`Prince,! 18%! in! Cap`Haitien,! 11%! in! Gonaïves,! 14%! in! Saint`Marc,! and! 15%! in! Petit`Goave.1153!Additionally,! 36%! of! Haitian! youth! reported! participation! in! a! group! or! organization! that! sought! to!preserve!the!environment!in!the!previous!year.1154!As!such,!while!many!Haitians!lack!confidence!in!state!institutions,!they!continue!to!seek!out!mechanisms!for!social!engagement!outside!of!this!state!system.!!In!the!months!following!the!2010!earthquake,!young!people!across!the!country!stepped!up!to!provide!leadership!in!affected!camps!and!communities.!Oxfam!notes!that!these!new!young!leaders!have!helped!large!numbers!of!people,!and! that! the!earthquake!allowed! them!to!discover!previously!unknown!and!unutilized!leadership!skills!and!talents.1155,1156!



1151!Gallup!Inc.,!Gallup&worldview&database:&Haiti.!Available!at!https://worldview.gallup.com/default.aspx!1152!G.!R.!Smucker,!Y.!F.!Pierre,!and!J.!F.!Tardieu,!Lost&childhoods&in&Haiti:&Quantifying&child&trafficking,&restavèks,&&&victims&of&violence,!Pan!American!Development!Foundation!Protecting!Human!Rights!Project!(November!2009).!Available!at!http://www.crin.org/docs/Haiti_lost_childhoods.pdf!!


1154!Gallup!Inc.,!Gallup&worldview&database:&Haiti.!Available!at!https://worldview.gallup.com/default.aspx!1155!Oxfam!America,!Haiti:&A&once5in5a5century&chance&for&change,!Oxfam!Briefing!Paper!136!(March!2010).!Available!at!http://www.oxfamamerica.org/publications/haitiàònceìnà`century`chance`for`change!!


!


7.&Health&

A.&Healthcare&access&!Healthcare! access! is! a! composite!measure! of! the! availability! of! health! infrastructure,! quality! of! staff!training!and!provided!services,!ease!of!travel!to!healthcare!facilities,!and!the!cost!of!healthcare!services,!among! others.! Before! the! earthquake,! Haitians! suffered! from! a! chronic! lack! of! access! to! healthcare!services! due! to! prohibitive! cost,! absolute! lack! of! healthcare! infrastructure! and! unequal! distribution!across!the!country,!a!shortage!of!trained!professionals,!and!a!culture!that!places!the!responsibility! for!the!health!of!many!women!in!the!hands!of!their!husbands.!As!a!result,!Haiti!has!consistently!performed!poorly!on!international!estimates!of!the!proportion!of!the!population!with!access!to!health!services.!!Between!1990!and!1992,!an!estimated!55%!of!the!population! lacked!access!to!healthcare.1157! In!2005,!the! National! Strategic! Plan! for! Health! Sector! Reform! (2005`2010)! stated! that! this! proportion! had!decreased! to! 47%,! with! significant! differences! among! Departments,! and! with! 50%! of! the! population!without! access! to! basic! drugs.1158! UNOCHA! estimated! that! 44%! of! seriously! ill! or! wounded! Haitians!lacked!access!to!health!services! in!2009!due!to!prohibitive!costs,1159!while!WFP!estimated!that!47%!of!Haitians!lacked!access!to!healthcare!in!2007.1160!These!discrepancies!may!result!from!true!changes!in!the!proportion!of!Haitians!with! access! to!healthcare,! but!may!also!be! the! result! of! different!methods! for!assessing!access,!as!well!as!the!civil!unrest!beginning!in!2004,!which!may!have!significantly!reduced!both!the!health!infrastructure!and!workforce!and!individuals’!willingness!to!travel!to!health!facilities.!!!As! is! occasionally! the! case! in!massive! humanitarian! relief! efforts,! access! to! basic! healthcare! actually!improved!for!many!Haitians!following!the!earthquake,!due!to!the!large!influx!of!medically!oriented!relief!organizations.! A! study! by! the!MIT! Lincoln! Laboratory! and!Harvard!Medical! School! found! that! 80%! of!respondents! in!Port`au`Prince!were!able!to!travel!to!medical! facilities! in! less!than!ten!minutes! in!April!2010,1161!while!Schiff!et&al.!found!that!the!majority!of!IDPs!nationwide!could!travel!to!health!services!in!less!than!thirty!minutes.1162!It!is!unclear!what!quality!and!range!of!services!were!provided!at!these!sites,!and!there!remains!the!longer`term!need!to!build!local!capacity!to!sustain!this!short`term!improvement!in!access,! since!30!of! the!49!hospitals!operating! in!earthquake`affected!areas!prior! to! the!earthquake!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1157!UNDP,!Human&development&report&1999:&Globalization&with&a&human&face!(New!York:!Palgrave!Macmillan,!1999).!Available!at!http://hdr.undp.org/en/reports/!!

1158!Cited!in!PAHO,!Health&in&the&Americas&2007:&Volume&II&–&countries:&Haiti!(2007).!Available!at!http://www.paho.org/hia/archivosvol2/paisesing/Haiti%20English.pdf!



1161!UN!OCHA!Haiti,!Haiti:&Humanitarian&assessment&key&findings&No.&4&(April!2010).!1162!L.!Ivers,!A.!Schiff,!D.!Jones,!et!al.,!“Assessment!and!analysis!of!Haitian!HADR!data”!(presentation!to!the!Haiti!Assessments!Working!Group,!April!27!2010).!

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were! either! damaged! or! destroyed,! and! numerous! health! sector! workers! were! killed.1163! In! its! Post`Disaster!Action!Plan,!the!Haitian!Government!identified!universal!health!service!access!as!a!high!priority!for!Haiti’s!reconstruction.1164!!The! high! proportion! of! health! services! provided! by! the! non`governmental! and! private! sector! in! Haiti!following!the!earthquake! is!not!a!new!phenomenon.! In!2006,!the!World!Bank!stated!that!only!30%!of!health! facilities!were! public,!with! the! remaining! 70%!operated! by!NGOs,! community! groups,! and! the!private!sector.1165!Public!health!facilities!are!concentrated!in!Portàu`Prince!and!other!urban!areas,!with!most!rural!inhabitants!forced!to!utilize!either!services!provided!by!NGOs,!which!provide!mainly!primary!healthcare,! or! the! private! sector,! with! higher! user! costs.1166,1167! In! addition! to! rural! areas,! the! slum!districts!of!Portàu`Prince!also!have!greater!rates!of!NGO!and!non`public!health!care!services.!According!to! PAHO,! healthcare! services! available! to! adolescents! (ages! 10`19)! are!mainly! provided! by! non`profit!groups,! rather! than!by! the!public! or! private! sector.1168! This! heavy! reliance!on!non`public! services! has!come!at!a!cost.!As!Salmi!noted!in!1998,!“private`sector!services!have!replaced!public!investment!rather!than! complemented! it,! and! their! rapid! and!unchecked! growth!has! significantly! undermined!efficiency!and!equity.”1169!!!Cost!was!the!primary!barrier!preventing!Haitians!from!accessing!healthcare!services!prior!to!the!January!2010!earthquake,1170,1171,1172!and!is!likely!to!reèmerge!as!the!primary!barrier!to!healthcare!access!due!to!the!withdrawal!of!earthquake!relief!healthcare!providers,!many!of!which!provided!free!services.!Private!







1169!Cited!in!World!Bank,!Social&resilience&and&state&fragility&in&Haiti:&A&country&social&analysis,!Caribbean!Country!Management!Unit,!Report!no.!36069`HT!(April!2006).!Available!at!http://siteresources.worldbank.org/SOCIALANALYSIS/1104894`1115795935771/20938696/Haiti_CSA.pdf!




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sector! service! providers,! some!NGO! providers,! and! the! public! sector! charge! upfront! fees! for! service,!which! places! healthcare! out! of! the! reach! of! many! Haitians,! especially! those! needing! advanced!treatment.1173,1174,1175,1176!In!2009,!out`of`pocket!expenses!accounted!for!a!significant!proportion!of!total!healthcare! spending,! placing! a! significant! burden! on! Haiti’s! poverty`stricken! population.! The! WHO!estimates! that! private! spending! accounted! for! 78.2%! of! all! health! spending! in! 2009.1177! The! cost! of!seeking! healthcare! has! exploded! over! the! past! 30! years.! In! fact,! PAHO! observed! that! the! cost! of! a!medical!consultation!has!increased!48!times!over!since!the!late!1980s,!from!25!Haitian!Gourdes!to!1,200!Gourdes.1178!As!a!result,!on!the!eve!of!the!earthquake!only!11%!of!Haitians!believed!that!healthcare!is!accessible!to!anyone,!regardless!of!income.1179!!To! promote! the! right! to! health! for! Haiti’s! children! requires! two! main! actions! of! the! government:!investment! in! raising! the! total! number! of! health! facilities! in! Haiti,! and! their! equitable! distribution!according! to! population! need! across! the! nation.! Haiti! has! a! paucity! of! healthcare! infrastructure! in!general,!and!the!current!maldistribution!of!existing!facilities!means!that!many!people,!especially!those!in!rural! areas,! do! not! have! access! to! the! care! they! need.1180! In! 1994,! interviews!with! 1,800!mothers! of!young!children!in!the!Central!Highlands!by!Coreil!et&al.!found!that!unpredictability!and!location!of!health!facilities!in!a!different!commune!to!where!they!were!living!had!an!even!greater!negative!effect!on!health!service!use!than!absolute!distance.1181!This!suggests!that!poor!knowledge!of!available!health!services!in!rural! areas! also! undermines! the! already! low! level! of! healthcare! accessibility.! In! 2008,! 90%! of! Haiti’s!1,859!physicians!were! located! in! the!Ouest!health!department!area,!which! includes!Port`au`Prince.! In!contrast,!a!report!from!2007!showed!that!13%!of!rural!residents!lived!more!than!15km!from!the!nearest!health!center.1182!Poor!transport!and!roads!act!as!a!disincentive!for!people!to!travel!these!long!distances!



1175!IFRC,!Haiti:&Earthquake&three&month&progress&report!(April!2010).!Available!at!http://www.ifrc.org/docs/appeals/10/MDRHT00814.pdf!



1179!S.!Crabtree,!J.!Godoy,!and!J.!Ray,!Survey&highlights&Haitians’&vulnerability:&Access&to&food,&shelter,&healthcare&less&prevalent&than&in&neighboring&countries,!Gallup!(January!2010).!Available!at!http://www.gallup.com/poll/125075/survey`highlights`haitians`vulnerability.aspx!!


1181!J.!Coreil,!A.!Augustin,!N.!A.!Halsey,!and!E.!Holt,!“Social!and!psychological!costs!of!preventive!child!health!services!in!Haiti,”!Social&Science&and&Medicine!38/2!(1994),!pp.!231`238.!


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when!traditional!healers!are!often!closer.1183!The!en&masse!movement!of!approximately!600,000!people!from!earthquakeàffected!areas! immediately! following!the!2010!earthquake!exacerbated!the!shortage!of! rural! health! facilities! as! displaced! people! competed! with! local! residents! for! already! inadequate!services.1184!!!As!noted!previously,!the!influx!of!relief!organizations!following!the!2010!earthquake!led!to!an!impressive!increase!in!the!ability!of!those!in!affected!areas!to!reach!healthcare!services,!with!80%!of!people!in!Portàu`Prince! able! to! travel! to! a! health! facility! in! less! than! ten! minutes1185! and! 86%! of! surveyed! sites!reporting!regular!health!service!provision.1186!Nonetheless,!the!earthquake!had!a!devastating!impact!on!healthcare!infrastructure!in!Portàu`Prince!and!other!affected!areas.!Of!the!49!hospitals!operating!in!the!disaster! zone!before! January!12,!2010,! thirty!were!damaged!or!destroyed!and!must!be! rebuilt!before!even! the! low! rates! of! physical! access! to! health! facilities! that! existed! prior! to! the! earthquake! can! be!attained! after! international! relief! groups! leave.1187,1188! During! Haiti’s! recovery,! the! Health! Cluster! has!recommended!building!an!additional!eight!hospitals!in!the!metropolitan!area!to!meet!the!population’s!needs.1189!!!In!addition!to!needing!better!and!more!equitably!distributed!healthcare! infrastructure,!Haiti!continues!to! face! a! chronic! shortage! in! its! health! workforce,! including! the! training! and! retention! of! doctors,!nurses,!and!other!health!professionals.!Compared!to!the!WHO!standard!of!25!health!professionals!per!10,000! people,! in! 2007! Haiti! had! only! 2.3! doctors! and! nurses! per! 10,000! people.1190,1191! This! is! a!reduction! in!coverage!since!1999,!when! it!was!estimated!that!there!were!a!combined!3.6!doctors!and!nurses! per! 10,000! people.1192! In! 2008,! the! International!Monetary! Fund! observed! that! emigration! of!health!professionals!and!Haiti’s!low!health!training!rates!have!significantly!reduced!the!country’s!ability!



1185!UN!OCHA!Haiti,!Haiti:&Humanitarian&assessment&key&findings&No.&4&(April!2010).!1186!UN!OCHA!Haiti,!Haiti:&Humanitarian&assessment&key&findings&No.&1,!22!March!2010!(March!2010).!Available!at!http://haiti.cridlac.org/XML/eng/doc90885/doc90885`contenido.pdf!!






1192!PAHO,!Regional&core&health&data&database:&Haiti.!Available!at!http://www.paho.org/english/sha/coredata/tabulator/newtabulator.htm!

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to!meet!the!WHO!standard!for!health!care!personnel.1193!Recognizing!the!need!to!increase!the!size!and!quality! of! the! domestic! health! force! in! the! wake! of! the! January! 2010! earthquake,! the! Haitian!Government! identified! strengthening! health! sector! human! resources! as! a! priority! in! its! Post`Disaster!Action!Plan,!including!at!the!oversight!and!leadership!level.1194!!Promoting! children’s! access! to! healthcare! will! also! require! addressing! cultural! norms! that! currently!disenfranchise!women! and! girls.1195! In! 2008,! UNICEF! noted!with! concern! that! husbands!made! all! the!health!decisions!for!over!21%!of!married!Haitian!women.1196!This!practice!challenges!child!protection!in!Haiti! on! two! fronts.! First,! as! children’s! primary! caregivers,!many! Haitian!women! are! unable! to!make!decisions! that!affect! their! children’s!quality!of! life;! this!decision! is! likely!made!by! their!husbands!who!may!not!play!as!significant!a!role!in!their!children’s!lives!as!the!mothers.!Second,!(as!noted!in!Section!3D.&Child&marriage)! in!2006!29.9%!of!girls!were!married!by!age!18.1197! It! is! likely! that! these!girls!have! less!autonomy! over! decisions! that! affect! their! health! due! to! their! young! age.! Strengthening! their!opportunities!to!overcome!a!social!practice!that!limits!their!health`seeking!behavior!should!be!a!priority!for!actors!working!to!protect!girls!and!promote!their!right!to!health.!!These! barriers! to! accessing! healthcare! have! led! to! very! low! levels! of! health! service! utilization.!Healthcare! utilization! is! often! defined! as! the! proportion! of! a! population! or! sub`population! (such! as!insurance!plan!members)!that!accesses!medical!services!each!year.!However,!international!child!health!surveys!and!statistics!instead!often!estimate!what!proportion!of!those!with!a!given!medical!need!is!able!to!access!healthcare!services.!This!process!controls!for!differences!in!underlying!disease!prevalence!and!focusses!on!the!ability!and!propensity!of! those! in!need!to!access!medical!care.!According!to!PAHO,! in!2006,! the!nationally`representative!EMMUS! IV! survey! found! that!although!40%!of! children!under! five!years! old! had! suffered! from! symptoms!of! acute! respiratory! infection! (ARI)! or! fever! in! the! two!weeks!preceding! the! survey,! only! 20%! of! these! children! had! been! taken! to! a! medical! professional! for! a!consultation!or!to!get!help.!Service!utilization!was!found!to!vary!by!residence!and!maternal!education,!with! 20%! of! women! living! in! urban! areas! seeking! medical! attention! when! their! child! displayed!symptoms! of! ARI! or! fever! compared! with! 18%! in! rural! areas.! Among! children! of! women! with! a!secondary!education!rates!of!seeking!care!were!28%,!compared!with!15%!among!those!whose!mothers!had!no!education.1198!However,!UNICEF’s!2008!State!of!the!World’s!Children!report!and!the!WHO!Global!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1193!IMF,!Haiti:&Poverty&reduction&strategy&paper,!IMF!country!report!No.!08/115!(2008).!Available!at!http://www.imf.org/external/pubs/ft/scr/2008/cr08115.pdf!!







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Health!Observatory!database!estimated!that!the!proportion!of!children!under!five!years!old!that!were!taken! to! an! appropriate! healthcare! provider! in! 2006! was! higher! (31%),1199,1200! despite! also! using! the!2006!EMMUS!IV!data.!It!is!unclear!why!these!sources!differ,!given!the!common!use!of!EMMUS!IV!survey!data,! though! one! possibility! is! that! the! definition! of! “appropriate! healthcare! provider”! may! include!healthcare!workers!not!captured!by!PAHO’s!definition!of!“medical!professional.”!Overall,!EMMUS!survey!data!from!the!Demographic!and!Health!Surveys!(DHS)!database! indicates!that,! though! low!in!absolute!terms,!the!proportion!of!children!under!age!five!who!were!taken!to!a!health!facility!after!displaying!ARI!symptoms!in!the!two!weeks!prior!to!the!survey!almost!doubled!between!1995!(16.8%!taken!to!a!health!facility)!and!2006!(31.5%!taken!to!a!health!facility).1201!!In! addition! to! urban`rural! residence! and! maternal! education,! the! EMMUS! IV! survey! also! found! that!healthcare!utilization!varied!by!socio`economic!status.!The!Government!of!Haiti!highlights!the!survey’s!finding!that!36%!of!sick!individuals!from!the!poorest!households!were!unable!to!access!medical!care!of!any!kind,!while!this!was!true!of!only!15%!of! individuals!from!rich!households.!Overall,!24%!of!those!in!need!were!unable!to!access!healthcare.1202!!In!assessing!healthcare!expenditure!in!Haiti,!Coreil!et&al.! found!in!1983!that!the!expenditure!of!money!and! time! depended!more! on! disease! type! than! prognosis.! In! fact,! these! authors! found! that! families!allocated!more!time!and!money!to!diseases!with!poor!prognoses,!possibly!because!illnesses!with!better!prognoses!were!more! likely!to!be!treated!at!home.!They!also!noted,!however,! that!no!time!or!money!was! spent! treating! neonatal! tetanus,! a! disease! believed! to! carry! no! chance! of! survival.! Overall,! the!authors! found! low!expenditures! for! infants,!with! families’!expenditure! for! child!health!peaking!at!age!three!and!then!decreasing!with!age!thereafter.!Resource!allocation!was!not!found!to!vary!by!sex!of!the!child!or!seasonal!variations!in!cash!flow,!though!larger!households!were!observed!to!invest!more!time,!but!less!money,!in!seeking!treatment!for!ill!children.1203!Though!the!study!did!not!measure!households!wealth!due! to! little! stratification!among! its! rural! sample!population!and! the!absence!of! rigorous!non`monetary!wealth!indexes!at!the!time,!the!finding!that!households!with!more!children!would!spend!less!money,! but! more! time,! on! treating! an! episode! of! child! illness! suggests! that! reducing! the! cost! of!healthcare!in!rural!areas!may!result!in!significantly!greater!access!and!utilization!rates,!especially!among!large!families.!!!Even!when!Haitians!do!manage!to!arrive!at!a!healthcare!facility,!they!often!find!it!is!of!poor!quality.!In!2006,! the!World! Bank! observed! that! private! healthcare! providers! existed! at! both! ends! of! the! quality!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1199!UNICEF,!State&of&the&world’s&children&2008!(Oxford:!Oxford!University!Press,!2008).!Available!at!http://www.unicef.org/sowc/!!

1200!WHO,!Global&health&observatory&database:&Haiti.!Available!at!http://www.who.int/gho/en/!1201!Demographic!and!Health!Surveys,!Measure&DHS&STATcompiler.!Available!at!http://www.statcompiler.com/!1202!Government!of!Haiti,!Enquête&mortalité,&morbidité&et&utilisation&des&services&(EMMUS&IV)&200552006!(January!2007).!Available!at!http://www.measuredhs.com/pubs/pdf/FR192/FR192.pdf!

1203!J.!Coreil,!“Allocation!of!family!resources!for!health!care!in!rural!Haiti,”!Social&Science&and&Medicine!17/11!(1983),!pp.!709`719.!

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spectrum,!with!access!to!high`quality!services!unaffordable!for!all!but!the!rich.1204!While!65%!of!wealthy!women!gave!birth!in!a!health!facility,!only!6%!of!Haiti’s!poorest!women!did!so.!The!Haitian!government!has! stated! that! the! expansion! of! the! private! sector! has! also! undermined! efficiency,! yielding! poor!outcomes!for!even!the!meager!US$32!per!capita!spent!on!healthcare.1205!As!a!result,!in!December!2008,!only! 22%!of!Haitians!were! satisfied!with! the! quality! and! availability! of! healthcare! in! their! area.1206! In!2006,!poor!availability!of!highly!skilled!staff!and!quality!equipment!compelled!49%!of!those!seeking!care!to!utilize!health!care!services!farther!from!their!homes!than!nearby,!lower!quality!services.1207!!!Disillusionment!with!the!quality!of!formal!healthcare!in!Haiti!and!the!litany!of!barriers!preventing!access!to!healthcare!services!has!led!most!of!the!population!to!seek!care!from!traditional!healers.!A!2009!study!found! that! 40%! of! victims! of! violence! sought! the! assistance! of! traditional! healers,1208! while! the! IFRC!found!in!2010!that!over!half!of!the!population!used!traditional!medicines!when!confronted!with!a!health!problem!and!many!relied!on!traditional!and!modern!medical!services!simultaneously.1209!!!In!studies!conducted!almost!three!decades!ago,!Coreil!explored!in!considerable!detail!the!factors!driving!Haitians!to!rely!on!traditional!healers.1210!Traditional!healers!were!mostly!consulted!for!common!medical!issues,! such! as! ARI,! diarrhea,! and! worms,! raising! concerns! that! children!may! be! taken! to! traditional!healers! more! often! than! the! general! population! as! they! are! relatively! more! likely! to! present! with!symptoms!of! these! diseases.! Coreil! noted! that! any! disease! can! be! seen! to! be! the! result! of,! and! thus!treatable!by,!Voodoo.!Ethno`medical!beliefs!are!based!on!the!hot`cold!humoral!system!of!classification,!whereby! chills,! palsy,! and! coughs! are! categorized! as! “cold,”! while! fever,! sweating! and! edema! are!categorized! as! “hot”.! Coreil! also! noted! that! medical! expenses! associated! with! traditional! medicine!accounted! for! a! greater! share! of! total! household! medical! expenditure! than! modern! medicine,! even!though! modern! healthcare! was! sought! for! two! thirds! of! all! treated! illnesses.! This! work! provides!background!to!the!conclusion!that!while!cost!is!the!primary!barrier!limiting!healthcare!access!in!Haiti,!it!is! the! multitude! of! barriers,! including! poor! quality,! poor! health! infrastructure! distribution,! and! a!



1206!S.!Crabtree,!J.!Godoy,!and!J.!Ray,!Survey&highlights&Haitians’&vulnerability:&Access&to&food,&shelter,&healthcare&less&prevalent&than&in&neighboring&countries,!Gallup!(January!2010).!Available!at!http://www.gallup.com/poll/125075/survey`highlights`haitians`vulnerability.aspx!!


1208!F.!Ponsar,!N.!Ford,!H.!M.!Van,!et!al.,!“Mortality,!violence!and!access!to!care!in!two!districts!of!Port`au`Prince,!Haiti,”!Conflict&and&Health!3/4!(2009).!


1210!J.!Coreil,!“Allocation!of!family!resources!for!health!care!in!rural!Haiti,”!Social&Science&and&Medicine!17/11!(1983),!pp.!709`719.!

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shortage!of!trained!staff,!that!together!undermine!children’s!enjoyment!of!the!right!to!health,!security,!and!holistic!protection.!&

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B.&Physical&health&!

i..Communicable.diseases.!Communicable!diseases!drive!childhood!mortality!in!Haiti.!While!overall!rates,!numbers!and!proportions!have! changed,! communicable! diseases! dominated! childhood!mortality! both! before! and! in! the! period!since!the!January!2010!earthquake.!Until!the!re`emergence!in!October!2010!of!cholera!—!a!disease!that!had! not! been! seen! in! Haiti! since! the! 1960s!—! large`scale! displacement,! overcrowding! in! camps! and!cities,! poor! sanitation,! and! childhood! malnutrition! had! not! resulted! in! significant! new! epidemics! or!outbreaks! of! communicable! diseases.1211! However,! even! in! pre`earthquake! years! the! young! Haitian!population! was! at! high! risk! for! contracting! communicable! diseases,! contributing! to! mortality! and!morbidity.!!!This! section! will! examine! eight! leading! non`sexually! transmitted! communicable! diseases! affecting!Haitian! children! before! and! after! the! January! 2010! earthquake,! as! well! as! the! coverage! of! national!immunization! and! vaccination! programs.! (Refer! to! Section! 7C.& Sexual& and& reproductive& health& for!information!on!HIV/AIDS!and!other!sexually!transmitted!diseases).!!The! 2005/06! EMMUS! IV! survey! found! that! acute! respiratory! infections! (ARIs)! and! diarrheal! diseases!were! the!most! prevalent! health! concerns! for! Haitian! children! under! age! five.! Approximately! 40%! of!these!children!had!ARI!symptoms! in! the! two!weeks!preceding! the!survey,!while!24%!had!experienced!diarrhea.1212,1213,1214!These!findings!confirmed!those!of!previous!studies!that!identified!diarrheal!diseases,!ARIs,! and!malnutrition! as! the!main! causes! of! infant!morbidity! and!mortality.1215! According! to! PAHO,!tuberculosis,! diarrheal! diseases,! malnutrition,! HIV/AIDS,! and! malaria! were! the! five! leading! causes! of!



1213!PAHO,!Health&situation&and&trends&summary:&Haiti!(2007).!Available!at!http://www.paho.org/English/DD/AIS/cp_332.htm!!



!


under`five!death!in!2007.1216! In!contrast,!the!WHO!Global!Health!Observatory!database!states!that!the!five! leading! causes! of! under`five! death! in! 2008! were! pneumonia! (22%),! diarrhea! (22%),! prematurity!(10%),!birth!asphyxia!(9%),!and!neonatal!sepsis!(5%),!with!“other!causes”!accounting!for!24%!of!deaths!in! this! age! group.1217! Discrepancies! between! these! estimates! may! be! explained! by! the! exclusion! of!neonatal!and!infant!causes!of!death!by!PAHO.!!For!children!in!the!5`14!year!age!range,!infectious!and!parasitic!diseases!constitute!the!major!threats!to!survival,!accounting!for!27%!of!deaths.1218,1219!Similar!to!the!under`five!age!group,!PAHO!stated!in!2007!that! tuberculosis,! diarrheal! disease,! malnutrition,! HIV/AIDS,! and! malaria! were! the! leading! causes! of!death!of! children! aged!5`9,! but! that! non`communicable! causes,! such! as! violence! and!accidents,!were!responsible!for!8%!of!deaths!in!this!age!group.1220!In!contrast,!the!International!Monetary!Fund!included!typhoid!among!the!leading!causes!of!mortality!in!the!5`14!age!group!in!2008.1221!!The!mortality! profile! of! adolescent! Haitians! (10`19)! differs! from! that! of! their! younger! peers,! as! non`communicable! causes! play! an! increasingly! important! role.! In! 2007! PAHO! stated! that! the! six! leading!causes!of!death!among!this!age!group!were!HIV/AIDS,!physical!assault,!accidents,!tuberculosis,!typhoid,!and!pregnancy`related! factors! (maternal!mortality).1222!Due! to!overlapping!age! categories!used! in! this!assessment,! the! prominence! of! communicable! diseases! among! adolescents,! such! as! TB! and! typhoid,!may! be! attributable! primarily! to! those! aged! 10`14,! with! non`communicable! causes! affecting!predominantly!older!adolescents!(aged!15`19).!!In!April!2010,!UNICEF!reported!that!injuries!were!the!primary!health!concerns!for!children!immediately!following! the! earthquake! and! that! this! increased! risk! returned! to! the! pre`disaster! level! after!approximately!three!months.!Communicable!diseases!and!their!risk!factors!were!found!to!be!mutually!reinforcing:!malnutrition!and!inadequate!hygiene!increased!the!risk!of!ARIs!and!diarrheal!diseases!while!contracting!these!diseases!increased!the!risk!of!malnutrition!and!other!communicable!diseases.1223!!!In!Haiti,!seasonal!rains!present!a!challenge!for!efforts!to!support!children’s!health.!UNICEF!has!expressed!these! concerns,! noting! that! the! arrival! of! seasonal! rains! is! associated! with! increased! morbidity! and!








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mortality!from!diarrhea,!ARIs,!and!malaria,!while!the!country’s!weak!infrastructure!also!limits!the!ability!of! responders! to! stock! and!operate! clinics,! feeding! centers,! and!other! interventions.! Seasonal! factors!have!clearly!compounded!the!detrimental!impact!of!the!earthquake!on!the!protection!and!promotion!of!children’s!health.1224!!!

Diarrheal(diseases(!Diarrheal! diseases! are! the! leading! cause! of! under`five! childhood!mortality! in! Haiti,1225! accounting! for!12.1%!of!deaths!in!this!age!group!in!1999,1226!22%!in!2008,1227!and!an!even!higher!percentage!since!the!cholera!epidemic!began! in!October!2010.!Diarrheal!diseases!are!also!a! leading!cause!of!mortality!and!morbidity!in!the!5`9,!10`14,!and!15`20!age!groups,!though!their!proportional!contribution!to!morbidity!and!mortality!decreases!with!age.!In!2003,!diarrheal!diseases!were!the!third!leading!cause!of!death!for!the!total!Haitian!population.1228!!The!primary!risk!factors!for!diarrheal!diseases!include!lack!of!access!to!uncontaminated!drinking!water,!poor!sanitation!such!as!ineffective!hand!washing,!and!inadequate!nutrition.1229,1230!These!risk!factors!are!compounded!by!a!high!population!density!that!facilitates!disease!transmission,!and!frequent!population!movement! bringing! infected! individuals! into! contact! with! others.1231,1232,1233! The! January! 2010!earthquake! exacerbated! these! risks,!making! the! Haitian! population,! especially! the! young,! even!more!susceptible!to!diarrheal!diseases.!As!noted!in!Section!6C.&Water,&sanitation,&and&hygiene,!more!than!80%!of!the!Haitian!population!lacked!access!to!adequate!sanitation!and!42%!lacked!access!to!clean!water!in!2006.!Unfortunately,!reliable!national!data!are!unavailable!for!the!post`earthquake!period.!While!many!





1229!UN!News!Center,!Cholera&inter5sector&response&strategy&for&Haiti:&November&2010&5&December&2011!(2011).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/8B2E07AB1A31BABEC12577D8004FE057`Full_Report.pdf!!





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in! IDP! camps!now!have!access! to! clean!water! and! sanitation! services! as! a! result! of! disaster! response!efforts,!slum`dwellers!and!other!sub`populations!remain!at!significant!risk.1234!!!As!Coreil!and!Genece!have!noted,!in!Haiti!“the!term!diarrhea!(diare)!is!used!to!denote!a!type!of!illness!as!well!as!a!symptom!of!other!illnesses.”1235!The!characterization!of!diarrhea!as!a!“hot”!illness!in!traditional!Haitian!medicine!motivated!the!widespread!use!of!traditional!“cooling”!remedies!(rafrechi)!for!diarrhea.!When! conventional! (Western! medicine)! treatment! has! been! used! and! perceived! as! ineffective,! the!probability! of! families! seeking! such! treatment! again! has! fallen,! and! the! belief! that! diseases! are!supernaturally!caused!has!further!spread.1236!To!date,!the!impact!of!these!traditional!beliefs!on!health`seeking!behavior! has!neither! been!assessed!more! generally! nor! in! the! specific! context! of! the! cholera!epidemic.!!The!most! recent! rigorous! national! estimate! of! the! prevalence! of! diarrheal! disease!was! conducted! in!2005!and!2006!as!part!of!the!EMMUS!IV!survey.!The!study!found!that!24%!of!under`five!Haitian!children!had!diarrhea!in!the!two!weeks!preceding!the!survey.1237!Prevalence!of!diarrheal!diseases!was!estimated!at!41%!for!Haitian!children!aged!6`11!months!(the!age!group!with!the!highest!prevalence)!and!at!38%!for!infants!aged!12`23!months.1238!The!high!prevalence!of!diarrheal!diseases!among!these!older!infants!may!be!attributed!to!the!transition!from!breastfeeding!to!other!sources!of!water!and!food.!!!In!the!month!following!the!January!2010!earthquake,!a!rapid!assessment!by!the!U.S.!Centers!for!Disease!Control!and!Prevention!(CDC)!revealed!that!diarrheal!diseases!were!the!second!most!common!disease!outbreak!across!55!surveyed!sites.!The!study!also!showed!that!28%!of!surveyed!sites! in!Port`au`Prince!and!47%!of!sites!outside!the!city!had!experienced!outbreaks!of!diarrheal!diseases.1239!While!these!data!were!not!necessarily!nationally!representative,!they!highlight!the!acute!impact!of!the!earthquake!on!the!population’s!susceptibility!to!communicable!diseases,!in!particular!intestinal!infections.!!Iterations!of!the!EMMUS!studies!prior!to!the!earthquake!suggested!increasing!usage!of!oral!rehydration!therapy! (ORT)! and! general! rehydration! to! care! for! children! with! diarrheal! diseases.! In! 2006,! 40%! of!children!with!diarrheal!diseases!were!treated!with!a!packet!of!ORT!while!an!additional!7%!were!treated!with!a!similar!homemade!solution.!Children!were!taken!for!a!medical!consultation! in!20%!of!diarrheal!cases.!Extra!fluids!were!also!provided!in!57%!of!cases!of!diarrhea!among!children!in!2006,!compared!to!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1234!D.!Sontag,!"In!Haiti,!capital!braces!for!cholera!outbreak,"!New&York&Times!(October!24,!2010).!Available!at!http://www.nytimes.com/2010/10/25/world/americas/25haiti.html?_r=1&hp!

1235!J.!Coreil!and!E.!Genece,!“Adoption!of!oral!rehydration!therapy!among!Haitian!mothers,”!Social&Science&&&Medicine!27/1!(1988),!pp.!87`96.!




1239!CDC,!CDC&summary&of&initial&rapid&assessment&conducted&by&UN&OCHA&in&Haiti!(February!2010).!

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41%!in!2000.!PAHO!found,!however,!that!the!use!of!any!form!of!oral!rehydration!is!higher!in!the!Port`au`Prince!metropolitan!area!(72%)!than!in!other!areas!(52%).1240!!!Although! use! of! ORT! and! general! rehydration! therapies! improved! between! the! 2000! and! 2005/06!EMMUS!surveys,!the!disparity!between!metropolitan!and!non`metropolitan!area!residents!highlights!the!need! for! continued! education! of! various! sub`populations! in! Haiti.! In! 1988,! Coreil! and! Genece’s!ethnographic!study!found!that!the!characteristics!of!decision`makers!were!more!important! in!deciding!the!course!of!treatment!than!the!attributes!of!a!diarrheal! instance.!Literacy!and!urban!residence!were!associated! with! a! greater! probability! of! using! ORT,! as! were! higher! socioeconomic! status! and! more!frequent!health`seeking!behaviors.!Notably,!those!who!began!ORT!use!early!in!the!course!of!illness!were!also!more!likely!to!report!that!ORT!cured!diarrhea!rather!than!it!just!replacing!lost!fluids.1241!!The! response! to!diarrheal! disease!prior! to! the!October!2010! cholera!epidemic!emphasized! risk! factor!mitigation! and! case! management,! thus! focusing! significantly! less! attention! on! the! education! of! the!general!population! than!was! the!case! following! the!emergence!of! the!cholera!epidemic.! In! July!2010,!UNICEF! noted! that! 1,770,000! Haitians! were! protected! from! cholera! through! the! distribution! of! 177!essential!drug!kits!to!treat!cases!of!communicable!diseases,!including!diarrhea.1242!The!Water,!Sanitation!and!Hygiene! (WASH)!Cluster!and! its!partners,! including! the!Haitian!Government,!had!made!significant!strides! in! improving! access! to! clean! water,! soap,! and! other! hygiene`related! necessities.! These! risk!reduction! interventions!arguably!played!a!significant!role! in!attenuating!the!cholera!outbreak,!and!are!discussed!in!greater!depth!in!Section!6C.&Water,&sanitation,&and&hygiene.!!!

Cholera(!Despite! the! concerted! efforts! of! domestic! and! international! responders,! including! the! Haitian!Government,!UN!agencies,!NGOs,!and!other!organizations,!October!2010!witnessed!the!beginning!of!a!national!cholera!epidemic!in!Haiti—the!first!large`scale!epidemic!since!the!January!2010!earthquake.!Its!emergence!presented!numerous! challenges! that!were!not! limited! to! the!health! sector.! In! addition! to!population!morbidity!and!mortality,!the!perception!that!international!responders!had!reintroduced!the!disease! to! Haiti! after! its! disappearance! in! the! 1960s! created! significant! tension! between! them!(especially!the!UN!peacekeeping!force!MINUSTAH)!and!the!Haitian!people.1243,1244!!




1243!"Building!a!safer!Haiti,"!New&York&Times!(Editorial,!September!19,!2011).!Available!at!http://www.nytimes.com/2011/09/20/opinion/building`a`safer`haiti.html!

!


!The! Haitian! Ministry! of! Public! Health! and! Population! (MSPP)! identified! the! first! cases! of! cholera! in!Artibonite! in!mid`October! 2010.1245! By! October! 19! 1,526! cases! had! been! identified! in! Artibonite! and!Centre,! and!MSPP! had! reported! 138! deaths.1246! Six!months! later! on! April! 4,! 2011,! a! total! of! 274,418!cases!and!4,787!deaths!had!been!reported!across!all!Departments!in!Haiti.1247!In!August!2011,!the!Health!Cluster! reported!that! the!number!of! identified!cholera!cases!had!reached!419,511!by!31! July!2011,!of!which! 222,359! had! been! hospitalized! and! 5,968! had! died,! but! that! case! fatality! rates! and! new! cases!were! slowing! in!most! Departments.1248! By! 1! January! 2012,! the! Haitian!Ministry! of! Public! Health! and!Population!(Le&Ministère&de&la&Santé&Publique&et&de&la&Population!–!MSPP)!reported!that!458,216!cholera!cases! had! been! identified! since! the! beginning! of! the! epidemic,! with! a! global! case! fatality! rate! of!approximately!1.4%.1249!!After!emerging!in!Artibonite!and!Centre!Departments,!the!cholera!epidemic!quickly!spread!throughout!Haiti! over! the! next! four! months.1250! Figure! 84! presents! the! number! of! cases! and! deaths! in! each!Department!by!February!2,!2011.!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1244!O.!A.!Adetayo,!A.!Gabriel,!and!S.!C.!Gupta,!"Haiti!and!the!road!to!recovery:!Surviving!the!human!aftershocks,!battles!with!the!cholera!epidemic,!and!the!anticipation!of!a!new!political!era,"!Plastic&and&Reconstructive&Surgery!128/2!(2011),!pp.!577`578.!


1246!PAHO,!EOC&situation&report&#1:&Cholera&outbreak&in&Haiti!(October!2010).!Available!at!http://new.paho.org/disasters/index.php?option=com_docman&task=doc_download&gid=1158!!


1248!Haiti!Health!Cluster,!Health&cluster&bulletin&27:&Cholera&and&post5earthquake&response&in&Haiti!(August!2011).!Available!at!http://new.paho.org/disasters/index.php?option=com_docman&task=doc_download&gid=1850!


cholera&in&Haiti)!(1!January!2012).!Available!at!http://mspp.gouv.ht/site/download.php?file=downloads/Rapport%20journalier%20MSPP%20du%2001%20janvier%202012.pdf!&


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Figure.84:.Geographic.variation.in.cumulative.cases.of,.and.deaths.from,.cholera,.20.October.2010T2.February.2011.

!†!Complete!data!were!not!available.!!‡!Excluding!Portàu`Prince.!!Source:!D.!Walton,!A.!Suri,!and!P.!Farmer,!“Cholera!in!Haiti:!Fully!integrating!prevention!and!care,”!Annals&of&Internal&Medicine!154/9!(2011),!pp.!635`637.!

!!PAHO! reported! in! August! 2011! that! the! global! attack! rate! (GAR)! of! Haiti’s! cholera! epidemic!was! 4%,!meaning!that!4%!of!the!total!Haitian!population!had!contracted!the!disease!since!the!beginning!of!the!epidemic.!Significant!differences!were!observed!between!Departments!and!areas!(Figure!85!and!Figure!86).!In!Portàu`Prince,!the!attack!rate!stood!at!7.1%!in!August!2011!while!SudÈst!experienced!an!attack!rate!of!approximately!0.9%.1251!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1251!Haiti!Health!Cluster,!Health&cluster&bulletin&27:&Cholera&and&post5earthquake&response&in&Haiti!(August!2011).!Available!at!http://new.paho.org/disasters/index.php?option=com_docman&task=doc_download&gid=1850!!

Cholera in Haiti: Fully Integrating Prevention and Care

The first cases of cholera after the 2010 earthquake inHaiti were reported in the Centre department; 4

months later, 215 936 cases had been reported across all 10of Haiti’s geographic departments, and among these, 1.9%(4131) of patients died (1). Because reporting capacity isweak in Haiti, these statistics probably underestimate thenumber of cases of cholera and the rate of spread. In thefirst months of the epidemic, case-fatality rates varied by10-fold across departments, ranging from 0.8% to 8% (2)(Table). For this reason, the article by Tuite and colleaguesin this issue (3) is timely and important.

The investigators used a mathematical model that con-siders both waterborne and person-to-person transmissionof cholera to predict the spread of the disease in Haiti. This“gravity” model predicts rates of disease transmissionamong regions on the basis of the population of a depart-ment and distance between departments. The model alsoattempts to assess the effects of 2 distinct interventions:vaccination on a limited scale and provision of clean waterat the same scale. Tuite and colleagues posit that adminis-tering a limited supply of 2-dose vaccines to 500 000 in-dividuals would reduce risk by 3%—twice the risk reduc-tion that would stem from provision of clean water to thesame number of individuals.

Although we believe that these results probably under-estimate the effect of both interventions, several conclu-sions can be drawn from this exercise. First, projectionsfrom the model show that morbidity and mortality duringthe epidemic phase of cholera is likely to last well into2011. This may in fact be an optimistic prediction for thecourse of the epidemic phase; as has been argued elsewhere,cholera may become endemic in Haiti (4). Second, byshowing the greater effect of earlier vaccination, Tuite andcolleagues’ study helps bolster the argument for initiatingand expanding cholera vaccination in Haiti as soon as pos-sible. Although vaccines can be effective even with limiteduse, broader and earlier intervention leads to greater riskreduction, highlighting the need for a global stockpile ofcholera vaccine to respond rapidly to epidemics. Third, thedual approach of vaccination and clean water illustrates thepositive synergies of a comprehensive strategy that com-bines multiple interventions.

In the context of economic scarcity, debate invariablyarises about the relative merits of investment in preventionversus care. Such debates about setting priorities in the faceof a new epidemic are not new. However, they weigh thevalue of competing interventions when in fact complemen-tary ones are needed. Cholera is no exception, and Tuiteand colleagues’ model is useful in assessing different ap-proaches, including vaccination strategies based on theconcentration of cases and the expected spread of the dis-ease (for example, whether the same number of dosesshould be given to each area or whether distribution should

be proportionate to population size). Such models canguide policymakers and administrators in designing opti-mal public health interventions.

Mathematical models such as these can also be usefulin tracking the nature and time course of an epidemicwhen surveillance efforts are constrained. Authorities havereported shortcomings in Haiti’s monitoring system(Thimothe G. Personal communication. 2011), which wasweak even before the earthquake leveled most of Haiti’sfederal government infrastructure, including the Ministryof Health. The very low numbers of nonhospitalized casefatalities strongly suggest that current monitoring effortsfail to capture many cholera victims, particularly in ruralareas, where cases are underreported and often untreated(Table). Although the first cases of cholera were detectedfairly quickly—a credit to the beleaguered Ministry ofHealth—the numerous nongovernmental organizationsand international assistance groups that provide health ser-vices have made centralized collection of case data throughthe Ministry of Health challenging (5), despite the good-will of and substantial assistance from partners rangingfrom the Cuban medical brigades to the U.S. Centers forDisease Control and Prevention.

How should policymakers make decisions that are in-formed by honest assessment of both local capacity andnew technologies, including vaccines? Decision analysismight prove useful in public health decision making andhelp to determine what resources should be invested toenhance the availability of clean water, diagnose and treatcholera, and distribute vaccines. Yet, these should not beenvisioned as competing strategies (6). Because cholera ispart of a vicious cycle of poverty, poor sanitation, watercontamination, and a weak health system, we argue for anapproach that combines prevention and care at every step.

Table. Geographic Variation in Cumulative Cases ofand Deaths From Cholera in Haiti, 20 October 2010 to2 February 2011*

Departmentor City

TotalCases,n

HospitalizedCase Fatalities,n

NonhospitalizedCase Fatalities,n

Case-FatalityRate, %

Artibonite 59 937 550 313 1.4Centre 18 958 180 173 1.8Grande’Anse† 13 026 324 521 6.2Nippes 1904 52 83 6.8Nord† 25 499 576 43 2.4Nord-Ouest 15 222 169 68 1.6Nord-Est 7922 104 144 3.1Ouest‡ 12 854 164 77 1.9Port-au-Prince 53 621 412 16 0.8Sud† 7532 138 45 2.4Sud-Est 2117 34 148 8.0

* Data are from reference 2.† Complete data were not available.‡ Excluding Port-au-Prince.

Annals of Internal Medicine Editorial

© 2011 American College of Physicians 635

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Figure.85:.Cumulative.incidence.of.reported.cholera.cases.per.1,000.population,.by.Department,.20.October.2010T31.July.2011.(graph).

!*Y`axis:!Cumulative!incidence!per!1,000!population!Source:!Haiti!Health!Cluster,!Health&cluster&bulletin&27:&Cholera&and&post5earthquake&response&in&Haiti!(August!2011).!Available!at!http://new.paho.org/disasters/index.php?option=com_docman&task=doc_download&gid=1850!!

!

Figure.86:.Cumulative.incidence.of.reported.cholera.cases.per.1,000.population,.by.Department,.20.October.2010T31.July.2011.(table).

!*Y`axis:!Cumulative!incidence!per!1,000!population!Source:!Haiti!Health!Cluster,!Health&cluster&bulletin&27:&Cholera&and&post5earthquake&response&in&Haiti!(August!2011).!Available!at!http://new.paho.org/disasters/index.php?option=com_docman&task=doc_download&gid=1850!!

HAITI HEALTH CLUSTER BULLETIN #27 – PAGE 3

Figures 1 and 2: Cumulative incidence of reported cholera cases (number of cases per 1,000

inhabitants), by department, 20 October 2010 – 31 July 2011

Cum.Inc/1000 in Hab

0

10

20

30

40

50

60

70

80

Centre

Grand'Anse

L'Artib

onite

Nippes

Nord

Nord-Est

Nord-Oue

st

Ouest Sud

Sud-E

st

Port-au

-Prin

ce Total

Département

Cum

.Inc/

1000

in H

ab

Cum.Inc/1000 in Hab

Department Cum.Inc/1000 in Hab Center 55.65 Grand Anse 46.55 Artibonite 56.45 Nippes 17.63 North 33.68 North-East 48.54 North-West 34.58 West 12.28 South 24.51 South-East 8.94 Port-au-Prince 70.78

Total 34.85

HAITI HEALTH CLUSTER BULLETIN #27 – PAGE 3

Figures 1 and 2: Cumulative incidence of reported cholera cases (number of cases per 1,000

inhabitants), by department, 20 October 2010 – 31 July 2011

Cum.Inc/1000 in Hab

0

10

20

30

40

50

60

70

80

Centre

Grand'Anse

L'Artib

onite

Nippes

Nord

Nord-Est

Nord-Oue

st

Ouest Sud

Sud-E

st

Port-au

-Prin

ce Total

Département

Cum

.Inc/

1000

in H

ab

Cum.Inc/1000 in Hab

Department Cum.Inc/1000 in Hab Center 55.65 Grand Anse 46.55 Artibonite 56.45 Nippes 17.63 North 33.68 North-East 48.54 North-West 34.58 West 12.28 South 24.51 South-East 8.94 Port-au-Prince 70.78

Total 34.85

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!!Of!particular!concern!during!the!first!months!of!the!epidemic!was!the!high!case!fatality!rate!(CFR),!or!the!percentage!of!people!who!died!of!the!disease.!Farmer!et&al.!noted!that!the!initial!CFR!of!7%!was!among!the!highest! in!recorded!history!and!that!the!2,000!cholera`related!deaths! in!the!first! forty!days!of! the!Haitian!epidemic!approached!half!the!total!number!recorded!in!Zimbabwe’s!year`long!cholera!epidemic!of!2008`09.1252!Six!months!later,!in!April!2011,!the!national!CFR!in!Haiti!had!dropped!to!1.7%,!with!Portàu`Prince!reporting!a!CFR!of!0.8%,!while!the!SudÈst!Department!continued!to!suffer!a!CFR!of!7.7%.1253!By! January! 1,! 2012,! the! national! CFR! had! fallen! to! 1.4%,! indicating! continued! improvements! in!treatment!and!disease!control.1254!This!rate,!however,!was!still!above!the!Sphere!Standard!indicator!for!cholera!CFR!of!1%!or!lower.1255!Analysis!of!MSPP!data!indicates!that!12.6%!of!all!cholera!cases!identified!by!January!1,!2012!were!among!children!under!age!5—approximately!proportional!to!their!share!of!the!total!Haitian!population—but!that!the!global!case!fatality!rate!for!this!age!group!(0.8)!was!almost!half!of!that!for!all!other!age!groups!combined!(1.4%).1256!!In! addition! to! improving! CFRs,! the! Health! Cluster! reported! that! the! incidence! of! new! cholera! cases!across!Haiti!was!decreasing!by!July!2011!(Figure!87).!In!the!four!months!leading!to!July!31,!2011,!cholera!activity!decreased!in!four!Departments,!while!activity!was!steady!in!three!others!and!in!Portàu`Prince.!A!minor!increase!in!cholera!activity!was!observed!in!Sud!Department,!while!the!Centre!Department!saw!a! reèmergence! over! this! period.! Though! relatively! stable! throughout! these!months,! cholera! activity!increased!in!NordÒuest!Department!in!the!final!two!weeks!of!July!2011.1257!!!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1252!P.!Farmer,!C.!P.!Almazor,!E.!T.!Bahnsen,!et!al.,!"Meeting!cholera's!challenge!to!Haiti!and!the!world:!a!joint!statement!on!cholera!prevention!and!care,"!PLoS&Neglected&Tropical&Diseases!5/5!(2011),!pp.!e1145.!



cholera&in&Haiti)!(1!January!2012).!Available!at!http://mspp.gouv.ht/site/download.php?file=downloads/Rapport%20journalier%20MSPP%20du%2001%20janvier%202012.pdf!&

1255!Sphere!Project,!Humanitarian&charter&and&minimum&standards&in&humanitarian&response!(2011).!Available!at!http://www.sphereproject.org/!!


cholera&in&Haiti)!(1!January!2012).!Available!at!http://mspp.gouv.ht/site/download.php?file=downloads/Rapport%20journalier%20MSPP%20du%2001%20janvier%202012.pdf!

1257!Haiti!Health!Cluster,!Health&cluster&bulletin&27:&Cholera&and&post5earthquake&response&in&Haiti!(August!2011).!Available!at!http://new.paho.org/disasters/index.php?option=com_docman&task=doc_download&gid=1850!!

!


Figure.87:.Trends.in.cholera.activity,.by.Department,.AprilTJuly.2011.

Department/area. . Trend.in.cholera.activity.NordÒuest! !! Increasing!Nord! "! Stable!NordÈst! "! Stable!Artibonite! #! Decreasing!Centre! $! Decreasing!June!to!mid`July,!increasing!mid`!to!late`July!Ouest! "! Stable!Portàu`Prince! "! Stable!SudÈst! #! Decreasing!Nippes! #! Decreasing!Sud! $! Stable/Slight!increase!Grand’Anse! #! Decreasing!

Data!source:!Haiti!Health!Cluster,!Health&cluster&bulletin&27:&Cholera&and&post5earthquake&response&in&Haiti!(August!2011).!Available!at!http://new.paho.org/disasters/index.php?option=com_docman&task=doc_download&gid=1850!!

!!While!the!above!estimates!of!cholera!cases,!mortality!and!trends!provide!some!indication!of!the!state!of!the! epidemic! in! Haiti,! the! Government,! Health! Cluster,! and! others! have! highlighted! that! current!surveillance!methods!may!underestimate! the! true! situation.! For! example,! low!hospitalization! rates!of!those! with! cholera! may! lead! to! underestimates! of! cases! and! CFRs.! Similarly,! the! low! numbers! of!reported!non`hospitalized!case!fatalities!suggest!that!many!cholera!victims!are!not!registered.1258!This!is!of!particular!concern! in!rural!areas,!where! lack!of!access!to!health!services!may!prevent!the!detection!and!treatment!of!cases!and!the!reporting!of!fatalities.1259,1260!Additionally,!the!centralized!collection!and!collation!of!disease!reports!from!the!litany!of!response!agencies!and!organizations!is!a!complex!process,!and! methods! may! not! be! accurate! or! standardized.1261! Despite! these! problems,! however,! the! data!remain!operationally!useful!until!better!surveillance!mechanisms!are!available.1262!!!Meanwhile,! several!models! have! been! developed! to! augment! decision`makers’! understanding! of! the!Haitian!cholera!epidemic!and!to!complement!sentinel!surveillance!efforts,! including!those!by!Andrews!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1258!D.!Walton,!A.!Suri,!and!P.!Farmer,!“Cholera!in!Haiti:!Fully!integrating!prevention!and!care,”!Annals&of&Internal&Medicine!154/9!(2011),!pp.!635`637.!


1260!P.!Farmer,!C.!P.!Almazor,!E.!T.!Bahnsen,!et!al.,!"Meeting!cholera's!challenge!to!Haiti!and!the!world:!a!joint!statement!on!cholera!prevention!and!care,"!PLoS&Neglected&Tropical&Diseases!5/5!(2011),!pp.!e1145.!



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and! Basu,1263! Chao! et& al.,1264! and! Tuite! et& al.1265! Of! particular! importance! to! programmers! and!policymakers!are!the!components!of!these!models!estimating!the!impact!of!proposed!interventions.!For!example,!in!their!analysis,!Andrews!and!Basu!estimated!that!over!a!nine`month!period!beginning!March!1,!2011,! improving!access! to!clean!water! to!an!additional!1%!of! the!population!per!week!would!avert!13.5%!of! cholera! cases! and! fatalities;! vaccinating! the!10%!of! the!population!most! at! risk!would! avert!8.1%!of!cases!and!fatalities;!and!expanding!the!use!of!antibiotics!to!50%!of!moderate!cases!would!avert!1.2%!of!cases!and!11.7%!of!fatalities.!Combined,!these!three!interventions!were!estimated!to!potentially!avert!21.8%!of!cases!and!30.6%!of!fatalities.1266!In!Andrews!and!Basu’s!analysis,!the!expansion!of!access!to!clean!water!would!be!the!single!most!effective!preventer!of!both!cholera!cases!and!fatalities.!!!Chao,!et&al.! also!used!a!model! to!estimate! the!potential! impact!of! cholera!vaccination.! In! this!model,!individuals! living! along! rivers! had! greater! risk! of! contracting! cholera! due! to! increased! likelihood! of!pathogen!exposure,!and! reactive!vaccination! in!high`risk!areas! (among!populations! living!along! rivers)!where! a! case! had! been! identified! alone! was! predicted! to! avert! the! same! number! of! cases! as! pre`vaccinating!slightly!less!than!half!of!Haiti’s!entire!population.1267!!Building! on! the! findings! of! sentinel! surveillance! systems! and! technical! support! from! a! range! of!stakeholders,! the! MSPP! released! the! National! Response! Strategy! to! the! Cholera! Epidemic! in! late!October!2010,!followed!by!the!supporting!Cholera!Inter`Sector!Response!Strategy!for!Haiti!developed!by!the!international!community!in!November!2010.!The!National!Response!Strategy!included!three!levels:!!

1. Protecting!families!in!the!community,!2. Strengthening!primary!health!care!centers!already!operating!across!the!country,!and!3. Establishing!a!network!of!special!Cholera!Treatment!Centers!and!strengthening!designated!

hospitals!for!treatment!of!severe!cases.1268!!The! Inter`Sector! Response! Strategy! highlighted! five! essential! components! of! the! national! plan.! These!are:!1)!Surveillance!systems;!2)!Case!management;!3)!Social!mobilization!and!health!promotion;!4)!Safe!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1263!J.!R.!Andrews!and!S.!Basu,!“Transmission!dynamics!and!control!of!cholera!in!Haiti:!an!epidemic!model,”!The&Lancet!377!(2011),!pp.!1248`1255.!

1264!D.!L.!Chao,!M.!E.!Halloran,!and!I.!Longini,!“Vaccination!strategies!for!epidemic!cholera!in!Haiti!with!implications!for!the!developing!world,”!Proceedings&of&the&National&Academy&of&Sciences&USA!108/17!(2011),!pp.!7081`7085.!

1265!A.!R.!Tuite,!J.!Tien,!M.!Eisenberg,!et!al.,!“Cholera!epidemic!in!Haiti,!2010:!Using!a!transmission!model!to!explain!spatial!spread!of!disease!and!identify!optimal!control!interventions,”!Annals&of&Internal&Medicine!154!(2011),!pp.!593`601.!

1266!J.!R.!Andrews!and!S.!Basu,!“Transmission!dynamics!and!control!of!cholera!in!Haiti:!an!epidemic!model,”!The&Lancet!377!(2011),!pp.!1248`1255.!

1267!D.!L.!Chao,!M.!E.!Halloran,!and!I.!Longini,!“Vaccination!strategies!for!epidemic!cholera!in!Haiti!with!implications!for!the!developing!world,”!Proceedings&of&the&National&Academy&of&Sciences&USA!108/17!(2011),!pp.!7081`7085.!


!


water!and!sanitation!in!health!facilities!and!communities;!and!5)!Provision!of!supplies!and!equipment!to!provide!a!comprehensive!response.”1269!!!Service! delivery! under! the! National! Response! Strategy! has! three! tiers:! 1)! Cholera! Treatment! Centers!(CTCs)!serving!as!standàlone!facilities!for!the!treatment!of!severe!cases!with!capacities!of!100`200!beds;!2)! Cholera! Treatment! Units! (CTUs)! that! are! attached! to! preèxisting! health! facilities! and! have! less!capacity! than!CTCs! (15`20!beds);!and!3)!Oral! rehydration!centers/posts! that! treat!non`life! threatening!cases.!Both!CTUs!and!oral! rehydration!centers/posts!provide!the!point!of!entry!to!treatment!and!care!services,!while!CTCs!are!designated! for!advanced!care!and! treatment.1270,1271!This! tiered!structure!was!designed! to! allow! preèxisting! health! care! facilities! to! continue! regular! operations! while! serving! the!needs!of!those!with!cholera!in!the!surrounding!community.1272!!Underlying!the!first!level!of!the!National!Response!Strategy!—!protecting!families!in!the!community!—!is!a! focus! on! risk! reduction! and! vulnerable! groups.! The! Strategy! notes! the! increased! risk! of! cholera!associated! with! high! population! densities! in! camps! and! slum! areas,1273! lack! of! adequate! water! and!sanitation! infrastructure,! and! low! levels! of! health! literacy! and! access! to! health! services.1274! Also!reflected! in! the! Strategy! is! a! focus! on!mobile! populations! and! seasonal! workers! who!may! carry! the!disease! to! other! communities! domestically! and! internationally.! The! National! and! Inter`Sectoral!Response! Strategy! identifies! serving! these! vulnerable! groups! and! addressing! population! health! risk!factors! as! priorities.1275! The! combination! of! preventative! and! curative! interventions! outlined! in! the!National!Response!Strategy!aims! to!provide!a!comprehensive! framework!and! response! to! the!cholera!epidemic.1276!!Recent! Health! Cluster! Situation! Reports! and! Bulletins! indicate! significant! success! in! meeting! the!objectives!of!the!National!Response!Strategy,!but!note!that!funding!restrictions!have!forced!the!closure!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1269!UN!News!Center,!Cholera&inter5sector&response&strategy&for&Haiti:&November&2010&5&December&2011!(2011).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/8B2E07AB1A31BABEC12577D8004FE057`Full_Report.pdf!!




1273!D.!Sontag,!"In!Haiti,!capital!braces!for!cholera!outbreak,"!New&York&Times!(October!24,!2010).!Available!at!http://www.nytimes.com/2010/10/25/world/americas/25haiti.html?_r=1&hp!

1274!D.!Sontag,!"In!Haiti,!capital!braces!for!cholera!outbreak,"!New&York&Times!(October!24,!2010).!Available!at!http://www.nytimes.com/2010/10/25/world/americas/25haiti.html?_r=1&hp!



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of!some!clinics.!By!August!5,!2011,!there!were!37!operational!CTCs!in!Haiti,!down!from!a!peak!of!101!in!January.!At!the!same!time,!206!CTUs!were!providing!treatment!and!care!across!Haiti;!a!slight!reduction!from!a! peak! of! 226! in!April.! In! addition,! 847! oral! rehydration! centers/posts!were! in! operation,! down!from!863!posts!in!mid`July!2011.!The!Health!Cluster!cites!funding!constraints!as!the!primary!reason!for!a!fall!in!service!delivery!centers,!especially!in!Nippes,!contributing!to!the!recent!increase!in!cholera!activity!in!that!Department.1277!!Despite! considerable! strides!made! in!Haiti’s! response! to! the! cholera! epidemic,! formidable! challenges!remain! in! both! the! short`! and! long`term.! Foremost! is! the! ability! of! the! Haitian! Government! and!response! community! to!maintain! and! improve! upon! gains!made! in! addressing! disease! incidence! and!CFRs! in! light! of! decreasing! financial! support! and! the! departure! of! international! responders! from!Haiti.1278,1279!Second!is!the!ability!of!stakeholders!to!extend!and!consolidate!the!provision!of!preventive!and!curative!services!to!those!in!rural!areas,!slums,!non`managed!camps,!children,!and!other!particularly!vulnerable! groups.1280,1281! Last! is! the! country’s! ability! to! transfer! the! structures,! processes,! tools,!methods,! and! lessons! learned! from! the! cholera! response! thus! far! and! apply! them! to! evolving! and!emerging! challenges.! As! noted! by! Walton! et& al.,! “vertical! programs! can! have! substantial,! positive!collateral! effects! in! strengthening! health! systems.”1282! The! fulfillment! of! this! potential! remains! to! be!seen!in!Haiti.!!!

Acute(respiratory(infections(!Less!is!known!about!the!current!impact!of!ARIs!on!children’s!health!and!wellbeing!in!Haiti!than!that!of!cholera!and!other!diarrheal!diseases.!Data!from!the!late!1990s!and!2000s!indicate!that!ARIs!accounted!for!approximately!6.9%!of!all!deaths!among!under`five!children!in!1999.1283!By!2008,!22%!of!under`five!deaths! were! caused! by! pneumonia.1284! The! 1994/95! EMMUS! II! survey! found! that! 20%! of! children!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1277!Haiti!Health!Cluster,!Health&cluster&bulletin&27:&Cholera&and&post5earthquake&response&in&Haiti!(August!2011).!Available!at!http://new.paho.org/disasters/index.php?option=com_docman&task=doc_download&gid=1850!!

1278!Haiti!Health!Cluster,!Health&cluster&bulletin&27:&Cholera&and&post5earthquake&response&in&Haiti!(August!2011).!Available!at!http://new.paho.org/disasters/index.php?option=com_docman&task=doc_download&gid=1850!!

1279!O.!A.!Adetayo,!A.!Gabriel,!and!S.!C.!Gupta,!"Haiti!and!the!road!to!recovery:!Surviving!the!human!aftershocks,!battles!with!the!cholera!epidemic,!and!the!anticipation!of!a!new!political!era,"!Plastic&and&Reconstructive&Surgery!128/2!(2011),!pp.!577`578.!


1281!O.!A.!Adetayo,!A.!Gabriel,!and!S.!C.!Gupta,!"Haiti!and!the!road!to!recovery:!Surviving!the!human!aftershocks,!battles!with!the!cholera!epidemic,!and!the!anticipation!of!a!new!political!era,"!Plastic&and&Reconstructive&Surgery!128/2!(2011),!pp.!577`578.!



1284!WHO,!Global&health&observatory&database:&Haiti.!Available!at!http://www.who.int/gho/en/!

!


displayed! symptoms! of! ARI! in! the! two!weeks! preceding! the! survey.1285! By! 2006,! this! proportion! had!doubled,!with! the!2005/06!EMMUS! IV! study! finding! that!40%!of! children!under! five! years!of! age!had!displayed!symptoms!of!ARI!within!the!preceding!two!weeks.1286,1287!!!Pre`earthquake!data! indicated!that! relatively! few!children!who!displayed!ARI!symptoms!presented! for!treatment,! although! estimates! vary! by! source.! Cayemittes! et& al.& reported! that! in! 1996,! only! 27%! of!children! with! ARI! symptoms! during! the! two! weeks! preceding! the! EMMUS! II! survey! were! taken! to! a!health! facility!or!medical!professional! for! treatment.1288!By!2006,! the!EMMUS! IV!survey! indicated!that!this!percentage!had!fallen!to!approximately!20%.1289!Differences!were!observed!between!children!living!in!urban!(26%)!and!rural! (18%)!areas,!and!between!children!whose!mothers!had!received!a!secondary!education!(28%)!and!those!who!had!not!(15%).1290,1291!In!contrast,!the!WHO!Global!Health!Observatory!and!Measure!DHS!databases!state!that!31.5%!of!under`five!children!displaying!ARI!symptoms!had!been!taken!to!a!health!facility! in!2006.1292!The!source!of!this!discrepancy!is!unclear,!as!these!sources!all!cite!EMMUS! IV! survey! data.! The! Countdown! to! 2015!MDG! Haiti! country! report! presented! a! significantly!different! analysis,! finding! that! the! percentage! of! children! under! age! five! with! suspected! pneumonia!taken! to!an!appropriate!health! care!provider! increased! from!17%! in!1995! to!31%! in!2006.1293!Despite!differing!in!size!and!trend,!these!sources!all!revealed!inadequate!access!to!and!utilization!of!health!care!facilities!by!children!displaying!symptoms!of!ARIs.!!The! January! 2010! earthquake! compounded! children’s! risk! of! acquiring! ARIs! due! to! overcrowding! in!camps,! inadequate!hygiene!and!access!to!clean!water,! lack!of!accessible!health!facilities,!poor!shelter,!










1292!WHO,!Global&health&observatory&database:&Haiti.!Available!at!http://www.who.int/gho/en/!1293!Millennium!Project,!Countdown&to&2015:&2010&Country&profiles:&Haiti!(2010).!Available!at!http://www.countdown2015mnch.org/documents/2010report/Profile`Haiti.pdf!!

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and! malnutrition.1294! Subsequent! rainy! seasons! accentuated! the! risk! of! acquiring! ARIs! while! limiting!responders’!ability!to!provide!treatment!services!to!those!in!need.1295!!!In! spite! of! the! challenges! to! ARI! prevention! and! treatment,! it! is! notable! that! ARIs! have! remained! a!secondary,!though!still!significant,!cause!of!child!morbidity!and!mortality!in!the!postèarthquake!period.!One!month! after! the! earthquake,! a! rapid! assessment! conducted! by! the! U.S.! CDC! found! that! 36%! of!surveyed!sites! in!Portàu`Prince!and!53%!of!sites!outside!Portàu`Prince!had!witnessed!an!outbreak!of!influenza.1296!Fortunately,!however,!high!ARI!prevalence!both!within!and!outside!of!Portàu`Prince!failed!to! translate! into!mortality! patterns! similar! to! those! witnessed! during! the! ongoing! cholera! epidemic.!Although!CFRs!for!cholera!in!the!absence!of!medical!care!are!typically!higher!than!those!for!pneumonia,!the!discrepancy!between!outbreak!prevalence!within!and!outside!Portàu`Prince!indicate!that!efforts!of!domestic! and! international! responders! may! have! mitigated! the! threat.! Medical! response! efforts!following! the! earthquake! included! the! distribution! of! emergency! essential! drug! kits! containing! ARI!treatments! and! the! establishment! of! numerous! health! posts! and! centers,! while! the! actions! of! the!Haitian!Government!and!the!international!community!in!certain!areas,!including!camp!management!and!the!provision!of!clean!water!and!hygiene!kits,!may!have!significantly!reduced!the!threat!posed!by!ARIs!to!Haiti’s!children.1297!Although!the!prevention!of!ARI`related!mortality!among!Haitian!children!remains!a!priority,!the!provision!of!timely!prevention!and!treatment!services!to!those!at!increased!risk!may!have!averted!a!larger!crisis!for!Haiti’s!children.!!!

Other(leading(diseases(of(concern(!In! addition! to! diarrhea! and! ARIs,! Haitian! children! face! many! other! health! challenges.! Of! particular!concern!are!TB,!malaria,!measles,!typhoid,!and!tetanus.!!Fewer! data! are! available! for! the! prevalence,! incidence,! and!mortality! rates! for! these! diseases! among!Haitian!children!than!for!diarrhea!and!ARIs.!Where!data!do!exist,!they!are!generally!aggregated!at!the!national! level!and!not!disaggregated!by!age.!As!such,!child`specific!and!other!sub`group!estimates!are!generally!unavailable!or!are!merely!extrapolated!from!estimates!from!the!total!population.!!Despite! these! limitations,! there! have! been! indirect! attempts! to! assess! the! impact! of! some! of! these!diseases.! Analysis! of! death! certificates! for! 1999,! for! example,! revealed! that! TB! was! one! of! the! five!leading! causes! of! death! for! all! Haitian! children,! although! the! proportion! of! deaths! attributable! to! TB!



1296!CDC,!CDC&summary&of&initial&rapid&assessment&conducted&by&UN&OCHA&in&Haiti!(February!2010).!1297!UNICEF,!Children&of&Haiti:&Milestones&and&looking&forward&at&six&months!(July!2010).!Available!at!http://www.unicef.org/emerg/files/UNICEF_Haiti_`_Six_Months_Report_Final.pdf!!

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varies!within!age!ranges.1298!In!2002,!Francis!et&al.!found!that!orphans!were!particularly!vulnerable!to!TB,!suggesting!that!1.125%!of!all!orphaned!Haitian!children!were!infected;!a!prevalence!that!is!significantly!higher! than! in! the! general! population.1299! In! 2009,! the!WHO!estimated! that! 0.3%!of! the! total!Haitian!population!was!infected!and!that!0.24%!of!the!population!contracted!TB!each!year.1300!Response!efforts!following! the! January! 2010! earthquake! recognized! the! considerable! potential! for! loss! of! life! and!antimicrobial! resistance!due! to! interruption!of! treatment! regimens.!As! a! result,!Dowell,! Tappero,! and!Frieden!highlight!that!by!April!1,!2010,!“67%!of!patients!on!preèarthquake!tuberculosis!registries!in!the!Portàu`Prince! area! were! again! receiving! medication.”1301! The! authors! also! note! that! up! to! 30%! of!patients!who!were!on!Portàu`Prince!TB!registries!may!have!perished!during!the!earthquake,!such!that!67%!treatment!resumption!may!actually!indicate!an!almost!complete!return!to!preèarthquake!levels!of!service!provision.1302!Nevertheless,! the! finding! in!2007! that!71%!of!people! infected!with!TB!died! from!the! infection! is! of! grave! concern,1303! even! given! the! rapid! reestablishment! of! treatment! delivery!following!the!earthquake.!

!Malaria!is!of!particular!concern!to!children!under!15!years!of!age!and!is!one!of!the!five!leading!causes!of!mortality!in!this!group.1304!PAHO!noted!that!in!2003,!12%!of!all!deaths!from!malaria!occurred!in!children!aged!less!than!five.1305!In!2009,!49,535!cases!of!malaria!were!reported!to!the!Ministry!of!Health,!while!it!was! estimated! that! there!were! approximately! 572!malarial! deaths! in! 2008.1306! In! 2006,! only! 5.1%! of!children! under`five! with! fever! were! treated! with! anti`malarial! drugs,! indicating! a! significant! gap! in!treatment!provision.1307!A!rapid!assessment!conducted!in!the!month!following!the!earthquake!showed!that!8%!of! surveyed!sites! in!Portàu`Prince!had!experienced!a!malaria!outbreak!since! the!earthquake,!compared!with!13%!of!sites!outside!the!city.1308!!!Increased!risk!of!malarial!outbreaks!due!to!rain,!water!pooling!and!stagnation,!and!inadequate!shelter!over! the! postèarthquake! period! prompted! UNICEF! and! its! partners! to! prioritize! the! distribution! of!insecticide`treated!bed!nets!and!malaria!medication.!Six!months!after!the!earthquake,!400,000!treated!


1299!J.!Francis,!A.!Reed,!F.!Yohannes,!et!al.,!“Screening!for!tuberculosis!among!orphans!in!a!developing!country,”!American&Journal&of&Preventive&Medicine!22/2!(2002),!pp.!117`119.!

1300!WHO,!Global&health&observatory&database:&Haiti.!Available!at!http://www.who.int/gho/en/!1301!S.!F.!Dowell,!J.!W.!Tappero,!and!T.!R.!Frieden,!“Public!health!in!Haiti!`!challenges!and!progress,”!New&England&Journal&of&Medicine!364/4!(2011),!pp.!300`301.!

1302!S.!F.!Dowell,!J.!W.!Tappero,!and!T.!R.!Frieden,!“Public!health!in!Haiti!`!challenges!and!progress,”!New&England&Journal&of&Medicine!364/4!(2011),!pp.!300`301.!

1303!DevInfo,!MDG&database&2010:&Haiti.!Available!at!http://www.devinfo.info/mdginfo2010/!1304!PAHO,!Health&in&the&Americas&2007:&Volume&II&–&countries:&Haiti!(2007).!Available!at!http://www.paho.org/hia/archivosvol2/paisesing/Haiti%20English.pdf!!


1306!WHO,!Global&health&observatory&database:&Haiti.!Available!at!http://www.who.int/gho/en/!1307!DevInfo,!MDG&database&2010:&Haiti.!Available!at!http://www.devinfo.info/mdginfo2010/!1308!CDC,!CDC&summary&of&initial&rapid&assessment&conducted&by&UN&OCHA&in&Haiti!(February!2010).!

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bed!nets!for!200,000!households!and!sufficient!medication!for!177,000!childhood!cases!of!malaria!had!been!distributed.1309!!!Measles! remains! an! intermittent! concern! for! Haitian! children.! Between! 1995! and! March! 2000,! no!measles!cases!were!reported!in!Haiti.1310!However,!990!cases!were!confirmed!during!2000,!and!another!158!cases!were!confirmed!in!2001.1311!In!2007,!PAHO!stated!that!no!further!cases!had!been!confirmed!since! 2001,! and! that! the! disease!was! on! track! for! elimination! in! Haiti.1312! The!UN! Committee! on! the!Rights!of!the!Child!attributed!the!epidemic!of!2000/01!to! low!immunization!coverage!rates,1313!a!topic!discussed!further!below.!!!Children! in! Haiti! also! remain! at! increased! risk! for! typhoid! in! the! post`earthquake! period.! Typhoid! is!endemic! in! Haiti! and! in! 2006! accounted! for! 2.7%! of! deaths! in! children! aged! 5`9,! 8.9%! of! deaths! in!children!aged!10`14,!and!3.2%!of!deaths! in!children!aged!15`19.1314!As!a!waterborne!bacterial!disease,!typhoid!is!of!particular!concern!in!overcrowded!settings!with!plentiful!water!and!inadequate!sanitation!and! hygiene.! Thankfully,! no! large`scale! outbreaks! of! typhoid! have! been! reported! in! post`earthquake!Haiti!despite!multiple!risk!factors.!!PAHO! reported! that! neonatal! tetanus! also! remains! a! significant! issue! confronting! children! in!Haiti.! In!2005,! 71! cases! were! reported,! a! large! percentage! of! the! total! 119! total! cases! of! tetanus! in! all! age!groups.!Incidence!of!neonatal!tetanus!varied!by!commune,!with!some!reporting!rates!of!over!1!case!per!1,000! live! births.1315! By! 2008,! the! number! of! neonatal! tetanus! deaths! had! fallen! to! 16,! while! an!additional!eight! tetanus!deaths!were! recorded! for! those!aged!under`five.1316!PAHO!also! reported! that!approximately!74%!of!women!giving!birth!between!2000!and!2005!had! received!at! least!one!dose!of!tetanus!vaccine!during!pregnancy.1317!!








1316!PAHO,!Regional&core&health&data&database:&Haiti.!Available!at!http://www.paho.org/english/sha/coredata/tabulator/newtabulator.htm!


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!

National(vaccination(program(!The! past! 15! years! have! seen! significant! progress! in! expanding! the! coverage! of! Haiti’s! national!vaccination!program.!This!program!includes! immunization!for!diphtheria,!pertussis,!and!tetanus!(DTP),!tuberculosis! (BCG),!measles,!and!polio.1318!The!1995!DHS!survey! found!that!only!30%!of!children!aged!12`23!months!were! fully! immunized! according! to! the! national! schedule,!with! children! living! in! urban!areas!more! likely! to! be! fully! vaccinated! than! their! rural! counterparts.1319! By! 2000,! the! proportion! of!children! in! this! age! group! who! were! fully! immunized! had! risen! to! 43%.1320! The! EMMUS! IV! revealed!further! improvements! in! complete! vaccination! coverage,! with! 54%! of! children! aged! 12`23! months!having! completed! the! full! vaccination! schedule! in!2006.1321,1322!UNICEF!has!noted! that! this! increase! in!vaccination! coverage! resulted! from! cooperation! between! the! WHO/PAHO,! MINUSTAH,! the! Haitian!Ministry!of!Health,!and!the!UNICEF!Haiti!country!office.!Together,!their!efforts!expanded!availability!of!essential! vaccines,! improved! supply! chain! systems,! and! mobilized! the! Haitian! population! to! seek!vaccinations!for!their!children.1323!!Improvements!in!immunization!coverage!can!be!observed!for!each!vaccine!in!the!national!program!over!the!period!1995`1999.!The!1995!EMMUS!II!survey!of!children!aged!12`24!months!found!coverage!rates!of!73%! for!BCG,!41%! for!DPT,!and!48%! for!measles.!By!1999,!85.5%!of!children! in! this!age!group!had!received!the!BCG!vaccine,!while!66.1%!had!received!the!DPT!vaccine,!81.4%!the!measles!vaccine,!and!59.6%!the!polio!vaccine.1324!!!Trends! in! vaccine! coverage! between! 2000! and! 2006! are! not! as! clear,! with! some! sources! suggesting!improvements!and!others!declines.!The!2005/06!EMMUS!IV!survey,!for!example,!found!that!only!57.7%!of!children!aged!12`23!months!had!received!measles!vaccination,!an!estimate!that,!while!low,!is!an!slight!improvement! over! the! 53.9%! coverage! rate! in! 2000.1325! The! cause! of! this! discrepancy! is! unclear.! The!World!Health!Organization!reported!that!by!2006,!the!proportion!of!children!who!had!received!the!full!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1318!PAHO,!Health&in&the&Americas&2007:&Volume&II&–&countries:&Haiti!(2007).!Available!at!http://www.paho.org/hia/archivosvol2/paisesing/Haiti%20English.pdf!!




services&survey!(2006).!Available!at!http://www.measuredhs.com/pubs/pub_details.cfm?id=767&srchTp=home!1321!UNICEF!Executive!Board,!Revised&country&programme&document:&Haiti&(200952011)!(2009).!Available!at!http://www.unicef.org/about/execboard/files/Haiti`FRS2009`revised_feb2010`English.pdf!

1322!UN!Committee!on!the!Rights!of!the!Child,!Consideration!of!reports!submitted!by!state!parties!under!article!44!of!the!Convention:!Haiti,!UN!Doc.!CRC/C/51/Add.7!(2002).!


1324!UN!Committee!on!the!Rights!of!the!Child,!Consideration!of!reports!submitted!by!state!parties!under!article!44!of!the!Convention:!Haiti,!UN!Doc.!CRC/C/51/Add.7!(2002).!


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course!of!DPT!vaccine!had!fallen!to!53%,1326!a!decrease!of!13%!compared!to!coverage!estimates!for!1999!presented!by!the!UN!Committee!on!the!Rights!of!the!Child!(UN!CRC).1327!!Vaccination!coverage!estimates!for!2005!by!PAHO!are!higher!than!those!found!during!the!EMMUS!IV!survey!(Figure!88),!but!generally!lower!than!those!presented!by!the!UN!CRC.!PAHO!reported!that!62%!of!children!aged!12`24!months!had!received! the!BCG!vaccine,!while!65%!had!been!vaccinated! for!polio,!and!68%!had!completed! the!DPT!vaccination!process.1328!!!By!2008,!the!WHO!and!UNICEF!estimated!that!75%!of!children!under!one!year!old!had!received!the!BCG!vaccine,!53%!had!received!all!three!DTP!vaccines,!and!that!52%!had!been!vaccinated!for!polio!and!58%!for!measles.1329!!Figure.88:.Expanded.Program.on.Immunization.coverage.rate.(%),.by.antigen,.2001T2005.

!Source:!PAHO,!Health&in&the&Americas&2007:&Volume&II&–&countries:&Haiti!(2007).!Available!at!http://www.paho.org/hia/archivosvol2/paisesing/Haiti%20English.pdf!!

!!Of!significant!concern!is!the!difference!in!vaccination!coverage!between!Departments.!According!to!the!WHO!and!UNICEF,! in!2008!44%!of!Haiti’s!133!health!districts!had!DTP! (DTP3)!coverage!of!under!50%,!while! only! 29%! of! districts! had! coverage! above! 80%.! Similarly,! only! 1%! of! health! districts! displayed!measles!immunization!coverage!of!over!90%.1330!!




1329!WHO/UNICEF,!WHO&and&UNICEF&estimates&of&immunization&coverage:&2010&revision:&Haiti!(2010).!Available!at!http://www.who.int/immunization_monitoring/data/hti.pdf!

1330!WHO/UNICEF,!WHO&and&UNICEF&estimates&of&immunization&coverage:&2010&revision:&Haiti!(2010).!Available!at!http://www.who.int/immunization_monitoring/data/hti.pdf!!

!


A!U.S.!CDC!rapid!assessment!conducted! in!the!month!following!the!2010!earthquake!noted!significant!data!gaps!regarding!measles!vaccination!coverage,!ranging!from!41%!of!camps!outside!Portàu`Prince!to!61%!within! Portàu`Prince! that!were!missing! data.1331! The! response! community! therefore! resolved! to!prioritize!childhood!vaccinations!within!health!service!delivery!interventions.1332!In!the!six!months!after!the! January! 2010! earthquake,! “more! than! 275,000! children! [were]! immunized! against!major! vaccine`preventable!diseases.”1333! By! the! end!of! 2010,!UNICEF! and! its!Health!Cluster! partners! had! vaccinated!approximately! 1,940,000! children! against!measles,! DTP,! rubella,! polio,! and! other! vaccine`preventable!diseases,!exceeding! the!program!target!of!1.5!million!children.!These!children!also! received!vitamin!A!supplements.! In! light! of! disparities! in! immunization! coverage! between! health! districts,! UNICEF! is!currently! focusing! vaccination! efforts! on! children! living! in! twenty! low`coverage! communities! and!expanding! its! vitamin! A! supplementation! program.1334! However,! in! the! absence! of! postèarthquake!national! assessments,! current! vaccine! coverage! data! for! the! postèarthquake! period! are! presently!unavailable.!!!

ii..NonTcommunicable.diseases.and.external.causes.!Non`communicable! diseases! consist! of! ailments! that! are! not! contagious,! such! as! cancers,! genetic!defects,! or! mortality! and! morbidity! resulting! from! external! causes.! ! In! Haiti,! there! is! very! little!information!about!the!prevalence!of!non`communicable!diseases!among!children!before!and!after!the!earthquake.!!!Prior! to! the! earthquake,! mortality! due! to! non`communicable! diseases! and! external! causes! was! a!significant! issue! for! children! in! Haiti.! Prematurity! accounted! for! the! largest! proportion! of! under`five!deaths!from!non`communicable!causes,!accounting!for!10%!of!all!deaths!for!children!in!this!age!group!in!2008,!followed!by!birth!asphyxia!(9%),!neonatal!sepsis!(5%),!injuries!(3%),!and!congenital!abnormalities!(2%).1335!In!2007,!PAHO!stated!that!8%!of!deaths!in!children!aged!5!–!9!were!due!to!external!causes,!with!girls!more! likely! to!be! victims!of! household! accidents! and!boys!more! likely! to!die! in! traffic! accidents.!Worryingly,! physical! assaults! and! accidents!were! also! among! the! top! ten! causes! of! death! of! children!aged!10`19!years.1336!Since!the!cessation!of!civil!unrest!mid`decade,! it! is!unclear!whether!this! remains!true!and!whether!endemic!violence!has!continued!to!present!significant!risks!to!Haitian!adolescents.!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1331!CDC,!CDC&summary&of&initial&rapid&assessment&conducted&by&UN&OCHA&in&Haiti!(February!2010).!1332!UNICEF,!Children&of&Haiti:&Progress,&gaps&and&plans&in&humanitarian&action!(April!2010).!Available!at!http://www.unicef.org/romania/FINAL_UNICEF_Haiti_90`Day_Report_13_April_2010_FINAL.pdf!!


1334!UNICEF,!Children&in&Haiti:&One&year&after&–&the&long&road&from&relief&to&recovery!(January!2011).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/10CF91515919332F49257811001C26F3`Full_Report.pdf!


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Both!before!and!after!the!earthquake,!a!significant!proportion!of!the!population!was!disabled!in!some!way.! In! 2008,! the! International!Monetary! Fund! found! that! 800,000! people,! approximately! 9%! of! the!country’s!then!population!of!9!million,!were!disabled.1337!Of!these!people,!200,000!were!estimated!to!be!children.1338!The!earthquake!has!undoubtedly!increased!the!proportion!of!the!population!suffering!from!disability,! injuring!an!estimated!300,000!people!of!all!ages.1339! In!March,! the!CNSA!rapid! food!security!assessment!found!that!5%!of!all!households!had!at!least!one!member!who!was!physically!handicapped,!including!those!disabled!prior!to!the!earthquake.!Regional!disaggregation!found!that!9%!of!households!in!Grand!Goâve!and!Croix`des`Bouquets!had!at!least!one!physically!disabled!member.1340!!!Between!15`19!January!2010,!Handicap!International!conducted!an!analysis!of!injuries!seen!by!its!staff!following!the!earthquake! in!Port`au`Prince! (Figure!89)!and!discovered!that! fewer!children!sought!care!for!earthquake`related!injuries!than!would!be!expected!given!their!share!in!the!total!Haitian!population.!Handicap! International! concluded! that! children! were! disproportionately! less! affected! than! older! age!groups!by! the!earthquake.!However,! a!degree!of! caution! is! advised!when! interpreting! this! conclusion!because! of! possible! selection! bias.! More! specifically,! the! study! contained! a! significant! discrepancy!between!the!numbers!of!boys!under!age!five!attended!to!than!girls,!potentially!indicating!either!a!sex`preference!within!households!in!prioritizing!care,!or!perhaps!that!the!small!age`specific!sample!size!was!too!small!to!reveal!the!true!population!proportion.!!Figure.89:.Proportion.of.patients.seen.by.Handicap.International.by.age.group.compared.to.Haitian.population,.19.January.2010..

Age. Total. M. F. Patient.Repartition.

Haiti.Pop..

<5! 18! 13! 5! 7%! 12%!5!`!17! 53! 27! 26! 20%! 32%!18!`!59! 172! 86! 86! 65%! 49%!>60! 21! 10! 11! 8%! 7%!Total! Known!Age!

264! 136! 128! 100%! 100%!

Unknown!Age!

18! 12! 6! 7%! !

TOTAL. . 52%. 48%. ! !Source:!UN!OCHA!Haiti,!Haiti:&Humanitarian&assessment&key&findings&No.&3,!5!April!2010!(April!2010).!Available!at!http://groups.google.com/group/assessmentshaiti/browse_thread/thread/71f3f127213f7a06!!


1338!UN!OCHA,!Humanitarian&bulletin:&3&May&–&6&June&2011!(2011).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/Full_Report_1060.pdf!

1339!Handicap!International,!18&months&of&action&in&Haiti!(July!2011).!Available!at!http://www.handicap`international.us/fileadmin/files/documents/July_2011_Haiti_18_mo_Sitrep.pdf!!


!


!!Of! those! patients! seen! by! Handicap! International! staff,! most! were! treated! for! fractures! (51%)! and!amputations! (35%),! with! smaller! percentages! treated! for! spinal! cord! injuries! (6%),! traumatic! brain!injuries! (3%),! burns! (2%)! and! other! problems! (4%).! It! was! estimated! that! between! 2,000! and! 4,000!amputations!were!conducted! in! the! first!month! following! the!disaster.1341!The!organization!notes! that!the! proportion! of! patients! receiving! amputation! was! far! higher! than! the! 2.5`5%! that! more! typically!characterize!post`!earthquake!orthopedic!injuries.1342!!In! 2009,! UNICEF! noted! that,! worldwide,! children! with! disabilities! face! increased! risks! and! associated!marginalization.!These!increased!risks!include!lower!likelihood!of!being!in!school!and!lower!educational!transition!rates,! lower!access! to!health!services,!and!vulnerability! to!physical,! sexual,!and!mental,!and!psychosocial! abuse.1343! Prior! to! the! earthquake,! Handicap! International! noted! that! people! with!disabilities! were! commonly! referred! to! as! “kokobés”! (“good! for! nothing’s”),! indicating! significant!stigma.1344!UNESCO!also!observed!that!prior!to!the!earthquake,!90%!of!disabled!Haitian!children!did!not!attend! school.1345! It! is!unclear!whether! increased! risks!and! stigma!will!persist! in!Haiti,!or!whether! the!sheer!prevalence!of!earthquake`related!disability!may!serve!to!reduce!associated!social!stigma.!!!In!2003,!the!Committee!on!the!Rights!of!the!Child!noted!with!disappointment!that!Haiti!did!not!have!a!comprehensive! strategy! for! children! with! disabilities,! and! lacked! data! measuring! vulnerabilities! and!service!utilization!rates!of!disabled!children.1346!In!the!wake!of!the!2010!earthquake,!the!need!for!these!data!and!the!formulation!of!a!strategy!to!promote!the!advancement!of!disabled!children!must!be!seen!as!an!integral!component!to!the!right!to!health!and!child!protection.!UN!OCHA’s!Humanitarian!Bulletin!of! 6! May`3! June! 2011! states! that! the! Secrétariat! d‘Etat! a! l’intégration! des! personnes! handicapées!(SEIPH)!has!created!a!policy!document,!“Cadre&programmatique&à&l’intention&des&intervenants&actuels&et&

potentiels& en& matière& de& handicap,”! outlining! major! focus! areas! of! support! for! disabled! persons,!including! health,! security,! education,! protection,! and! access! to! basic! social! services,1347! though! the!degree!of!implementation!and!impact!of!this!policy!are!not!yet!known.!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1341!Handicap!International,!18&months&of&action&in&Haiti!(July!2011).!Available!at!http://www.handicap`international.us/fileadmin/files/documents/July_2011_Haiti_18_mo_Sitrep.pdf!!



1344!Handicap!International,!18&months&of&action&in&Haiti!(July!2011).!Available!at!http://www.handicap`international.us/fileadmin/files/documents/July_2011_Haiti_18_mo_Sitrep.pdf!

1345!UN!OCHA,!Humanitarian&bulletin:&3&May&–&6&June&2011!(2011).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/Full_Report_1060.pdf!!


1347!UN!OCHA,!Humanitarian&bulletin:&3&May&–&6&June&2011!(2011).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/Full_Report_1060.pdf!!

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C.&Sexual&and&reproductive&health&!

i..Reproductive.health.!Reproductive! health! risk! factors! and! outcomes! carry! serious! consequences! for! children! and! their!mothers!in!Haiti.!Available!data!indicate!that!programs!and!policies!undertaken!to!improve!reproductive!health!in!Haiti!over!the!past!two!decades!have!seen!positive!results,!although!issues!including!unwanted!pregnancy,!maternal!mortality,!and!low!rates!of!professionally!assisted!delivery!have!persisted.1348!The!January! 2010! earthquake! significantly! compromised! Haiti’s! ability! to! continue! recent! gains! as! health!facilities! were! destroyed,! medical! professionals! were! killed,! and! risk! factors! such! as! anemia! and!malnutrition! threatened! to! undermine! clinical! interventions.! In! light! of! these! challenges,! the! Haitian!Government! has! included! the! development! of! reproductive! health! services! among! its! post`disaster!priorities.1349!Such!service!development!may!be!expected!to!enhance!the!health!of!Haitian!women!and!children! greatly! because! “antenatal! care,! skilled! attendance! at! birth,! emergency! obstetric! care,! post`partum! care,! contraception! and! family! planning! delivered! across! a! continuum! of! care…! can! have!multiple! benefits! for! both!mother! and! child,”1350! and! because!maternal! causes! were! one! of! the! five!leading!causes!of!adolescent!mortality!prior!to!the!earthquake.1351!!As! noted! in! Section! 3E.& Mortality,! Haiti’s! Maternal! Mortality! Ratio! (MMR)! is! a! significant! cause! for!concern.!Estimates!of!Haiti’s!MMR!are!high,!but!different!sources!vary!significantly.!In!2008,!the!Haitian!Government!reported!a!MMR!of!630!deaths!per!100,000!live!births,1352!while!UNICEF!models!estimated!that!Haiti’s!MMR!was!300!maternal!deaths!per!100,000!live!births.1353!According!to!a!2008!estimate!by!the!Population!Reference!Bureau,!women! in!Haiti!had!a!1! in!93! lifetime! risk!of!dying! from!maternity`related! causes.1354! ! This! probability! is! due! to! the! combination! of! high! fertility! rates! and! high! rates! of!death!per! live!birth.! The!high!prevalence!of! adolescent!pregnancy! in!Haiti! is! of! particular! concern,! as!adolescent!mothers!younger!than!15!are!five!times!more!likely!to!die!during!childbirth!than!are!women!in! their! twenties.1355! Conclusions! regarding!Haiti’s! progress! in! reducing!maternal!mortality! depend!on!








!


the! data! source.! National! estimates! have! indicated! deterioration! over! the! past! twenty! years,! with!estimates!increasing!from!457!deaths!per!100,000!live!births!in!1990!to!630/670!deaths!per!100,000!live!births!in!2006.1356!However,!UNICEF!and!WHO!models!estimating!Haiti’s!MMR!at!300!deaths!per!100,000!live!births!have!indicated!a!significant!improvement!over!that!period.!Reasons!for!the!improvements!in!Haiti’s!MMR!between!2000!and!2006!are!unclear,!and! the!progress!does!not!appear! to!have! resulted!from! the! expansion! of! medical! supervision! of! births,! as! the! proportion! of! childbirths! attended! by! a!medical!professional!appears!to!have!remained!relatively!stable,!increasing!from!24%!in!20001357!to!26%!in! 2006.1358!Maternal!Mortality!Ratio! estimates! for! the!period! following! the! January!2010!earthquake!remain!unavailable.!!Analysis!of!the!causes!of!maternal!mortality!indicates!that!most!maternal!deaths!in!Haiti!can!be!avoided!through!appropriate!antenatal!care!and!expanding!access!to!professionally!assisted!childbirth.!In!2003,!29%! of! maternal! deaths! were! caused! by! complications! in! childbirth,! such! as! hemorrhage,! while!hypertension! and! eclampsia! were! implicated! in! 26%! of! cases,! and! a! further! 13%! were! attributed! to!unsafe!abortions.1359!!!In!addition!to!maternity`related!deaths,!Unite!for!Children!and!UNICEF!have!noted!that!globally,!for!each!woman!who!dies!during!childbirth,!another!twenty!experience!significant!morbidity.!Common!causes!of!maternal!morbidity! include! “injury,! infection,! disease! and!disability”! stemming! from! fistula! and!other!outcomes! that! significantly! compromise!women’s! ability! to! participate! in! their! family! and! community!environments.!These!outcomes!not!only!affect!the!health!and!wellbeing!of!the!women!themselves,!but!also!their!ability!to!care!and!provide!for!their!children.1360!!Haiti! has! experienced! consistently! low! rates! of! births! attended! by! skilled! health! staff.! Professionally!assisted!delivery!is!a!crucial!component!of!efforts!to!reduce!Haiti’s!MMR.!Skilled!attendance!facilitates!the!safe!completion!of!typical!pregnancies,!while!also!providing!immediate!care!or!referral!in!the!event!of!complications,!which!are!not!reliably!predictable.!For!this!reason,!appropriate!delivery!care!requires!a!well`functioning! healthcare! system,! including! the! presence! of! skilled! staff,! so! that! women! in! need!receive!timely!medical!attention.!In!this!regard,!rural!women!in!Haiti!are!particularly!disadvantaged,!due!to!both!lack!of!skilled!staff!to!attend!deliveries,!as!well!as!lack!of!nearby!health!facilities!for!referral.1361!The! destruction! of! health! facilities! during! the! 2010! earthquake! weakened! an! already! inadequate!



1358!Population!Reference!Bureau,!PRB&datafinder:&Haiti.!Available!at!http://www.prb.org/datafinder.aspx!1359!PAHO,!Health&in&the&Americas&2007:&Volume&II&–&countries:&Haiti!(2007).!Available!at!http://www.paho.org/hia/archivosvol2/paisesing/Haiti%20English.pdf!!



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healthcare! system,! further! compromising! the! ability! of! Haitian! women,! and! especially! those! in! rural!areas,!to!receive!appropriate!medical!supervision!of!deliveries.!!Estimates!of! the!percentage!of!births! attended!by!a!medical!professional!differ!by! source.! The!World!Bank! and! the!WHO!estimated! that! in! 2000,! 23.8%!of! births!were!medically! supervised.! By! 2004,! this!proportion! had! increased! to! 26.1%,! but! did! not! demonstrate! any! further! improvement! by!2008.1362,1363,1364! The! International! Monetary! Fund! estimated! that! in! 2006,! only! 24%! of! births! were!attended! by! skilled! health! staff.1365! In! contrast,! estimates! provided! by! other! organizations! have!suggested! much! higher! coverage! of! professionally! supervised! deliveries.! According! to! PAHO,! the!2005/06!EMMUS!IV!survey!found!that!60%!of!deliveries!were!attended!by!either!a!medical!professional!or! skilled! midwife,! although! PAHO! noted! that! the! EMMUS! III! survey’s! finding! that! only! 24.7%! of!deliveries!occurred!in!a!health!facility!may!better!indicate!the!true!situation.1366!!!The!proportion!of!births!attended!by!a!health!professional!varies!significantly!by!urban/rural!and!socio`economic! status.! Although! the! EMMUS! III! survey! found! that! 60%! of! deliveries!were! supervised,! only!53%!of!deliveries!in!rural!areas!were!attended!by!a!medical!professional!or!midwife,!while!the!same!was!true! of! 74%! of! deliveries! in! urban! areas.1367! Additionally,! UNICEF! and! Unite! for! Children! found! that!deliveries! by! women! in! the! highest! wealth! quintile! were! 12.3! times! more! likely! to! be! medically!supervised! (68%)! than! those!of!women! in! the! lowest!wealth!quintile! (6%).! The!proportion!of!women!whose!births!were!attended!by!trained!health!staff!was!lower!for!each!wealth!quintile!in!Haiti!than!for!women!in!equivalent!quintiles!in!Honduras,!Bolivia,!and!Peru!(Figure!90).1368!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1362!World!Bank,!Genderstats&database:&Latin&America&and&the&Caribbean.!Available!at!http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTGENDER/EXTANATOOLS/EXTSTATINDDATA/EXTGENDERSTATS/0,,contentMDK:21442622~menuPK:4851685~pagePK:64168445~piPK:64168309~theSitePK:3237336,00.html!

1363!WHO,!Epidemiological&fact&sheet&on&HIV&and&AIDS:&Haiti!(December!2008).!Available!at!http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_HT.pdf!!






!


Figure.90:.Percentage.of.births.attended.by.skilled.health.personnel,.by.household.wealth.quintile,.2003T2006.

!Source:!UNICEF,!Progress&for&children&number&7:&A&report&card&on&maternal&mortality!(September!2008).!Available!at!http://www.unicef.org/progressforchildren/files/Progress_for_Children`No._7_Lo`Res_082008.pdf!!

!!The!WHO’s!Global!Health!Observatory!stated!that! in!2006,!30.1%!of!births!among!adolescent!mothers!were!attended!by!skilled!health!professionals,!potentially!indicating!higher!levels!of!birth!supervision!in!this! group! than! in! their! older! counterparts.1369! However,! the! 2005/06! EMMUS! IV! survey! found!significantly! lower! prevalence!of! skilled! delivery! attendance! among! adolescents! in! rural! areas! than! in!urban!areas,!and! large!differences!between!Departments! (Figure!91).1370!Overall,!approximately!97.5%!of! births! by! both! adolescents! age! 15`19! and! youth! age! 20`24! were! assisted! by! some! other! person!(including! non`medical! persons),! and! approximately! 63.5%! were! attended! by! either! a! health!professional!or!trained!birth!attendant.!Deliveries!by!adolescents!living!in!urban!areas!were!more!likely!to!be!attended!by!a!health!professional!(44.6%)!than!those!of!adolescents!living!in!rural!areas!(27.6%),!while! adolescent! births! in! rural! areas! were! more! likely! to! be! attended! by! a! trained! birth! attendant!(29.7%)!than!those!to!adolescents!in!urban!areas!(27.2%).!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1369!WHO,!Global&health&observatory&database:&Haiti.!Available!at!http://www.who.int/gho/en/!1370!Population!Council/UNFPA,!The&adolescent&experience&in5depth:&Using&data&to&identify&and&reach&the&most&


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Figure.91:.Percentage.of.women.aged.15T24.who.received.delivery.assistance.from.various.types.of.service.providers,.by.Department.and.urban/rural.status,.2006.



!!Tong!et&al.!note!that!since!the!January!2010!earthquake,!safe!delivery!services,!as!well!as!antenatal!and!postnatal! care,! were! provided! for! free! by! many! public! and! international! response! health! facilities,!improving!rates!of!medically!supervised!deliveries.1371!However,!the!recent!reduction!in!the!number!of!NGOs!operating!in!Haiti,!as!well!as!the!concentration!of!relief!efforts!in!the!Port`au`Prince!metropolitan!area,!raise!concerns!regarding!both!the!sustainability!and!equity!of!this!increase!in!delivery!supervision.!!Antenatal!care!reduces!the!risk!of!maternal!mortality!and!morbidity!through!the!early!identification!and!treatment! of! risk! factors! such! as! anemia,! malnutrition,! and! hypertension.1372! Additionally,! antenatal!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1371!K.!Tong!and!F.!Gaillardin,!Adolescent&sexual&and&reproductive&health&assessment&mission&to&PLAN,&Haiti!(July!2010).!


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consultations!provide!an!avenue!for!prospective!mothers!to!gather!information!and!other!services!that!may! assist! them! before,! during,! and! after! childbirth.! For! example,! the! WHO,! UNICEF,! and! UNAIDS!identified! the! potential! of! integrating! voluntary! HIV! counseling! and! testing! (VCT)!with! antenatal! care!services.!As!a!result,!100%!of!antenatal!care!facilities!reportedly!also!provided!VCT!services!in!2008.1373!!The! International! Monetary! Fund! (IMF)! reported! that! the! proportion! of! pregnant! Haitian! women!attending!at! least!one!antenatal!visit! increased!over! the!past!15!years.!The! IMF!and!others!estimated!that!in!1995,!67.7%!of!pregnant!women!had!attended!at!least!one!antenatal!checkup!during!pregnancy!but!that!this!proportion!had!increased!to!78.8%!by!2000,!and!84.5%!by!2006.1374,!1375,!1376,!1377!Similarly,!the!World!Bank!estimated! in!2006!that!87.5%!of!pregnant!Haitian!women!aged!15`19!receive!at! least!one!antenatal!care!consultation.1378!!However,!in!2006!IMF!estimated!that!only!54%!of!pregnant!women!had!received!the!recommended!four!antenatal!visits!in!2006,!indicating!that!service!gaps!still!remain.1379!!!According! to! the! EMMUS! IV! survey,! pregnant! adolescents! aged! 15`19! received! 3.8! antenatal! care!consultations! in! 2006,! though! notable! differences! existed! between! Departments! (Figure! 92).1380!Pregnant! adolescents! aged! 15`19! attended! only! 2.5! antenatal! care! visits! in! Centre! Department,!compared! to! an! estimated! 4.8! visits! in! Ouest! Department.1381! Somewhat! surprisingly,! the! average!number!of! antenatal! care! visits! attended!by! adolescents! suggests! that! they! are!more! likely! to! attend!antenatal!care!checkups!than!older!Haitian!women,!although!concerns!remain!that!available!antenatal!services!are!not!young!person`friendly.1382!!!






services&survey!(2006).!Available!at!http://www.measuredhs.com/pubs/pub_details.cfm?id=767&srchTp=home!1378!World!Bank,!World&development&indicator&database.!Available!at!http://databank.worldbank.org/ddp/home.do?Step=12&id=4&CNO=2!







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Figure.92:.Mean.number.of.antenatal.care.visits.among.pregnant.females.aged.15T24,.2006.

!Source:.Population!Council/UNFPA,!The&adolescent&experience&in5depth:&Using&data&to&identify&and&reach&the&most&


!!

ii..Sexual.health.!Sexual!health!is!of!particular!concern!for!Haitian!adolescents.1383!Early!sexual!debut,!multiple!concurrent!partnerships,! and! low! rates! of! condom! use! place! young! Haitians! at! heightened! risk! for! sexually!transmitted!diseases!(STDs).!Many!Haitian!girls!experience!increased!vulnerability!to!STDs!due!to!sexual!violence!and!age!disparities!with!older!partners.1384!Haiti!has!the!highest!HIV!prevalence!of!any!country!




!


in!the!Western!Hemisphere,1385!and!high! levels!of!knowledge!about!HIV!and!other!STDs!have!failed!to!translate!into!effective!preventative!behavior!for!most!adolescent!Haitians.!!Nationally!representative!data!on!the!prevalence!of!STDs!other!than!HIV,!generally,!and!for!adolescents,!specifically,! are! unavailable.! Available! STD! information! is! drawn! from! a! limited! subset! of! women!attending! health! facilities.! A! 1996! study! of! 476! women! attending! antenatal! services! at! the! Hospital!Albert!Schweitzer! in! the!Artibonite!Valley! found!that!25.4%!of! these!women!had!trichomoniasis,!2.3%!had! gonorrhea,! 10.7%! had! chlamydia,! 6.8%! had! syphilis,! and! 4.3%!were! HIV! positive.! In! total,! 40.1%!presented!with!one!or!more!STDs.1386!Troublingly,!the!median!age!of!women!presenting!with!gonorrhea!was!19!years.!The!study!authors!noted,!given!the!association!between!young!age!and!susceptibility!to!cervical! infection,! the! trend! towards! earlier! sexual! debut! and! activity! may! contribute! to! increased!transmission!of!gonorrhea!and!chlamydia.1387!A!similar!study!conducted!among!women!seeking!care!at!a!women’s!health!clinic!in!the!Peligre!basin!between!June!1999!and!March!2001!found!that!5%!of!women!had!chlamydia,!6%!had!chlamydia!and/or!gonorrhea,!13%!had!trichomoniasis,!4%!had!syphilis,!and!more!than!3%!were!HIV!positive.1388! It! should!be!noted! that! the!estimates!derived!by! these!studies!are!not!generalizable!to!the!total!Haitian!population!due!to!factors! including!the!non`randomness!of!sampling!procedures,!the!limited!geographic!scope,!and!the!small!sample!sizes!of!the!studies.!!As! noted! above,! age! of! sexual! debut! is! an! important! risk! factor! contributing! to! Haitian! adolescents’!sexual! health.! Iterations! of! the! EMMUS! surveys! indicate! that! the! proportion! of! Haitian! males! and!females!having!sex!before!ages!15!and!18!increased!between!1995!and!2006!(Figure!93).1389!In!1995,!9%!of! females! and! 17%! of! males! age! 15`24! had! experienced! sexual! debut! by! age! 15,! while! these!proportions!had!increased!to!15%!and!43%!by!2006,!respectively.1390!Aggregated,!23%!of!Haitian!youth!aged!15`24! in!2006!had!experienced!sexual!debut!by!age!15;1391!however,!sex!disaggregation!provides!more!meaningful! estimates!due! to! the! significant!observed!disparities!between!males! and! females.! A!1995! study!of!Haitian! 20`24! year! olds! found! that! 41%!of! females! and!53%!of!males! had!experienced!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1385!M.!Loudon,!A&study&of&integrated&interventions&for&children&made&vulnerable&by&HIV/AIDS&in&Haiti:&A&case&study&


1386!D.!W.!Fitzgerald,!F.!Behets,!A.!Caliendo!A,!et!al.,!“Economic!hardship!and!sexually!transmitted!diseases!in!Haiti’s!rural!Artibonite!Valley,”!American&Journal&of&Tropical&Medicine&and&Hygiene!62/4!(2000),!pp.!496`501.!

1387!D.!W.!Fitzgerald,!F.!Behets,!A.!Caliendo!A,!et!al.,!“Economic!hardship!and!sexually!transmitted!diseases!in!Haiti’s!rural!Artibonite!Valley,”!American&Journal&of&Tropical&Medicine&and&Hygiene!62/4!(2000),!pp.!496`501.!

1388!M.!C.!Smith!Fawzi,!W.!Lambert,!J.!M.!Singler,!et!al.,!“Prevalence!and!risk!factors!of!STDs!in!rural!Haiti:!implications!for!policy!and!programming!in!resource`poor!settings,”!International&Journal&of&STD&&&AIDS!14!(2003),!pp.!848`853.!

1389!UNAIDS,!Children&and&AIDS:&A&stocktaking&report!(January!2007).!Available!at!http://www.unicef.org/publications/index_38048.html!!


services&survey!(2006).!Available!at!http://www.measuredhs.com/pubs/pub_details.cfm?id=767&srchTp=home!1391!WHO,!Epidemiological&fact&sheet&on&HIV&and&AIDS:&Haiti!(December!2008).!Available!at!http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_HT.pdf!!

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sexual! debut! by! their! 18th! birthday.! ! By! 2006,! these! proportions! increased! to! 53%! and! 76%,!respectively.1392,1393!!!Figure.93:.Percentage.of.young.Haitians.who.had.first.intercourse.before.15.or.before.18,.by.sex,.1995T2006.

!Source:.Institut!Haitien!de!l’Enfance,!HIV/AIDS&in&Haiti:&Key&findings&of&the&mortality,&morbidity,&and&utilization&of&

services&survey!(2006).!Available!at!http://www.measuredhs.com/pubs/pub_details.cfm?id=767&srchTp=home.!!In!addition!to!fertility!considerations,! low!rates!of!condom!use!among!Haitian!adolescents!raise!sexual!health! concerns,! especially! in! cases! of! multiple! concurrent! partnerships.! As! described! in! Section! 3C.&Fertility,!condom!use!varies!by!location!and!marital!status!(Figure!94).!Nationally,!20%!of!young!women!(age!15`24)!reported!using!a!condom!at!last!sex!in!2006.!Young!women!in!urban!areas!were!more!likely!to!have!used!a!condom!at!last!sex!(27.6%)!than!their!rural!counterparts!(12%).!Young!women!who!had!never!married!were!more!likely!to!have!used!a!condom!at!last!intercourse!(36.9%)!than!those!married!with!one!or!more!children!(7.2%)!or!no!children!(20.3%).1394!A!2009!study!of!3391!sexually!active!young!people!age!13`25!attending!the!GHESKIO!health!center!in!Port`au`Prince!found!that!65%!of!females!and!52%!of!males!had!never!used!a!condom.1395!!!






1395!T.!Dorjgochoo,!F.!Noel,!M.!M.!Deschamps,!et!al.,!“Risk!factors!for!HIV!infection!among!Haitian!adolescents!and!young!adults!seeking!counseling!and!testing!in!Port`au`Prince,”!Journal&of&Acquired&Immune&

Deficiency&Syndromes!52!(2009),!pp.!498`508.!

!


Figure.94:.Percentage.of.females.aged.15T24.who.used.a.condom.at.last.sex,.2006.



!!Available! data! suggest! that! neither! knowledge! of! where! to! obtain! condoms! nor! a! married! woman’s!ability!to!ask!a!husband!to!use!a!condom!if!the!husband!has!a!known!STD!are!limiting!factors!for!condom!use.!The!2005/06!EMMUS!IV!survey!found!that!more!than!90%!of!women!in!both!urban!and!rural!areas!felt!that!a!wife!could!ask!a!husband!to!use!a!condom!in!such!cases.!A!post`earthquake!study!by!Tong!et&al.! also! found! high! levels! of! knowledge! regarding! transmission! routes! of! STDs! and! treatment!locations.1396!The!EMMUS!IV!found!that!76%!of!women!aged!15`19!and!81%!of!women!aged!20`24!knew!where!to!obtain!condoms,!while!this!was!true!of!82%!of!men!aged!15`19!and!91%!of!men!aged!20`24!in!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1396!K.!Tong!and!F.!Gaillardin,!Adolescent&sexual&and&reproductive&health&assessment&mission&to&PLAN,&Haiti!(July!2010).!

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2006! (Figure! 95).1397! Reasons! for! the! disparity! between! knowledge! of! where! to! obtain! condoms! and!condom!use! in!these!age!groups!remain!unclear.!However,!a! localized!study!of!845!15`19!year!olds! in!Nord! Department! showing! that! 43%! of! respondents! had! had! three! or! more! sexual! partners,!substantially!increasing!the!risk!of!acquiring!HIV!and!other!STDs!highlights!the!need!to!fill!this!data!gap!so! that! evidence`based! policies! and! programs! reducing! this! discrepancy! may! be! developed! and!implemented.!!Figure.95:.Knowledge.of.source.for.condoms.and.condom.use.at.first.sex,.ages.15T19.and.20T24,.by.sex,.2006.


services&survey!(2006).!Available!at!http://www.measuredhs.com/pubs/pub_details.cfm?id=767&srchTp=home!.!One!possible!cause!of!low!condom!use!rates!may!be!age!differences!between!young!women!and!their!typically! older! male! partners.! The! UNFPA! and! Population! Council! have! found! that! age! differences!between! partners! reduce! young! women’s! ability! to! negotiate! safe,! voluntary,! and! protected! sexual!relations.1398!Analysis!of!EMMUS!IV!survey!data!for!Haiti!showed!that!the!male!partner!was!older!than!the!female!in!84%!of!cases!of!sexual!debut!among!15`24!year!old!females!in!2006,!and!that!the!man!was!ten!or!more!years!older!in!11%!of!these!cases!(Figure!96).!In!only!5.2%!of!first!sexual!intercourse!was!the!man!either!the!same!age!or!younger!than!the!woman.1399!Similar!age!differences!have!been!observed!when! comparing! the! ages! of! young!women! and! their! current! partner,! rather! than! their! first! partner!(Figure!97).!Nearly!three`quarters!(74.5%)!of!women!aged!15`24!were!less!than!ten!years!younger!than!







!


their! current! partner,! while! 18.1%! were! ten! or! more! years! younger,! and! only! 7.5%! of! these! young!women!were!the!same!age!as,!or!older!than,!their!current!partner.1400!!Figure.96:.Age.difference.between.partners.at.first.sex.among.females.age.15T24,.2006.



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Figure.97:.Age.difference.between.current.partners.among.females.age.15T24,.2006.



!!While! contributing! to! a! smaller! percentage! of! overall! STD! infections! than! unprotected! sexual!intercourse,!unsafe!blood!transfusions!also!carry!the!risk!of!expanding!the!prevalence!of!STDs.!A!2005!screening!of!11,000!blood!units!found!that!1.6%!of!units!carried!HIV,!4%!carried!Hepatitis!B,!0.7%!carried!Hepatitis!C,!1%!carried!HTLV`1,!and!3%!tested!positive!for!syphilis.1401!As!such,!even!those!young!people!not! engaged! in! sexual! activity! remain! at! risk!of! contracting! “sexually! transmitted!diseases.”! The!2010!National!Report!to!UNGASS!states!that!by!2009,!100%!of!blood!units!were!screened!for!HIV,!although!it!remains!unclear!whether!these!units!are!also!screened!for!other!STDs.1402!


1402!Government!of!Haiti,!Rapport'de'situation'nationale'à'l’intention'de'l’UNGASS:'Période'Janvier'20085Décembre(2009!(March!2010).!Available!at!http://www.unaids.org/en/dataanalysis/monitoringcountryprogress/2010progressreportssubmittedbycountries/haiti_2010_country_progress_report_fr.pdf!

!


HIV/AIDS(!The!HIV/AIDS!epidemic!in!Haiti!is!the!most!prevalent!in!the!Western!Hemisphere.1403!According!to!World!Bank! models,! women!make! up! more! than! half! (59.8%)! of! all! of! those! with! HIV! in! Haiti,1404! and! the!country! demonstrates! a! generalized! epidemic,! driven! by! heterosexual! sex! and! mother`to`child!transmission.1405,1406!HIV/AIDS!was!one!of! the! leading! five! causes!of!death! for!adolescents!aged!10`19!prior! to! the! January! 2010!earthquake,! accounting! for! 5.8%!of! all! certified!deaths! in! this! age! group! in!1999.1407,1408!!!While! Haiti’s! HIV! prevalence! remains! high,! available! estimates! indicate! that! significant! progress! has!been!made!in!reversing!the!epidemic.!In!2001`03,!an!estimated!5.5%!to!6%!of!the!adult!population!aged!15`49!were!HIV`positive.1409,1410,1411!By!the!2006/06!EMMUS!IV!survey,!Haiti’s!HIV!prevalence!had!fallen!significantly! to!an!estimated!2.2%!of! the!adult!population.1412,1413,1414,1415,1416,1417,1418,1419!Prevalence!was!found!to!vary!significantly!by!Department,!with!the!highest!adult!prevalence!found!in!Nippes!(3%),!and!




1405!UNAIDS,!Helping&Haiti&rebuild&its&AIDS&response!(February!2010).!Available!at!http://data.unaids.org/pub/FactSheet/2010/20100226_haiti_aidsresponse_en.pdf!!

1406!PEPFAR,!2008&Country&profile:&Haiti!(2008).!Available!at!http://2006`2009.pepfar.gov/press/81593.htm!1407!PAHO,!Health&situation&and&trends&summary:&Haiti!(2007).!Available!at!http://www.paho.org/English/DD/AIS/cp_332.htm!!










1416!PEPFAR,!2008&Country&profile:&Haiti!(2008).!Available!at!http://2006`2009.pepfar.gov/press/81593.htm.!1417!UNAIDS,!Helping&Haiti&rebuild&its&AIDS&response!(February!2010).!Available!at!http://data.unaids.org/pub/FactSheet/2010/20100226_haiti_aidsresponse_en.pdf!!



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the! lowest! in!Sud`Est! (1.4%).1420!By!2009,!World!Bank!models!estimated!that!the!adult!HIV!prevalence!had!fallen!to!1.9%.1421,1422!However,!it!is!unclear!whether!this!reduction,!or!magnitude!thereof,!is!due!to!a!true!reduction!in!HIV!prevalence,!or!a!change!in!methods!used!to!estimate!prevalence!from!sentinel!surveillance!of!pregnant!women!to!population`based!techniques.!!!HIV! prevalence! in! children! under! 15! years! of! age! is! relatively! lower! than! that! for! their! adult!counterparts.! In! 2000,! Family! Health! International! estimated! that! approximately! 20,000! children,! or!0.7%!of! the! population! under! age! 15,!were!HIV`positive.1423!However,! the!World!Health!Organization!estimated!that!far!fewer!children!were!infected!with!HIV!in!2001,!estimating!that!4,700!children!aged!0`14!were!HIV`positive,1424!while!the!World!Bank!estimated!that!there!were!12,000!children!under!age!15!living!with!HIV!in!that!year.1425!In!contrast!with!estimates!suggesting!a!reduction!of!adult!HIV!prevalence,!the!WHO!estimated! that! there!were!more!Haitian! children! living!with!HIV! in!2007! than! in!2001,!with!6,800!children!estimated!to!be!HIV`positive,1426,1427,1428!while!UNICEF!reported!that! in!2007!there!were!approximately! 19,000! children! living! with! HIV.1429!World! Bank! estimates! fall! between! these! findings,!estimating! that! there! were! 13,000! HIV`positive! children! in! Haiti! in! 2007.! By! 2009,! the! World! Bank!estimated!that!the!number!of!children!under!15!living!with!HIV!had!fallen!to!approximately!12,000.1430!Modeled! findings! presented! in! the!most! recent!Haiti! Country! Report! to!UNGASS! (2010)! estimate! the!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1420!Government!of!Haiti,!Rapport&de#situation#nationale#à#l’intention#de#l’UNGASS:#Période#Janvier#20085Décembre(2009!(March!2010).!Available!at!http://www.unaids.org/en/dataanalysis/monitoringcountryprogress/2010progressreportssubmittedbycountries/haiti_2010_country_progress_report_fr.pdf!








1427!Global!Health!Council,!Haiti&and&HIV&after&the&earthquake!(March!2010).!Available!at!http://www.globalhealth.org!!




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number!of!children! living!with!HIV!to!be!8,700! in!2009,!falling!between!estimates!provided!by!UNICEF!and!the!WHO.1431!!!According!to!the!WHO,!HIV!prevalence!in!Haitian!youth!(15`24!years)!was!higher!than!in!children!0`14,!with! an! estimated! prevalence! of! 0.6%! among! males! and! 1.4%! among! females! in! this! age! group! in!2007.1432! By! 2009,! the! prevalence! of! HIV! among! female! youth! had! dropped! by! a! tenth! of! a! percent!according! to! the!World!Bank,! although!HIV!prevalence!among!male! youth! remained! constant.1433! The!disparity!between!male!and!female!HIV!prevalence!in!this!age!group!supports!the!argument!that!large!age!differences!between!partners!negatively!affect!the!younger!females,!as!the!older!partners!of!these!young!women!are!more!likely!to!be!HIV`positive!than!men!of!the!same!or!younger!age!as!their!female!partners.!!!In!2010,!UNICEF!stated!that!each!year,!approximately!5,000!Haitian! infants!contract!HIV.1434!However,!Family!Health! International!noted! that! in!2001,!approximately!90%!of!HIV`positive! children!die!within!their!first!year!of!life.1435!This!extremely!high!rate!of!HIV`related!mortality!among!Haitian!infants!partially!explains! why! childhood! HIV! prevalence! remains! low! despite! significant! adult! prevalence,! although! it!should!be!noted!that!the!expansion!of!treatment!services!over!the!past!decade!may!have!significantly!reduced!the!infant!HIV!case!fatality!rate.!!Significant! investments! by! the! Haitian! Government,! the! international! community,! and! other! service!providers! resulted! in! a! rapid! expansion!of! access! to! antiretroviral! treatment! (ART)! coverage!between!2004!and!2009,!although!coverage!remained!relatively! low!prior! to! the! January!2010!earthquake.!The!WHO! estimated! that! in! 2004,! only! 10%! of! people! living! with! HIV! had! access! to! ART.! By! 2007,! the!estimated! proportion! had! increased! to! approximately! 41%,! indicating! significant! gains! over! the! four`year! period.1436! In! total,! 13,000! people!were! believed! to! be! receiving! ART! in! 2007.! By! 2009,! UNAIDS!noted!that!this!number!had!increased!to!24,000!HIV`positive!individuals!of!an!estimated!32,000!people!in!need,!for!an!overall!coverage!rate!of!75%.1437!Meanwhile,!the!Haiti!Country!Report!to!UNGASS!stated!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1431!Government!of!Haiti,!Rapport'de'situation'nationale'à'l’intention'de'l’UNGASS:'Période'Janvier'20085Décembre(2009!(March!2010).!Available!at!http://www.unaids.org/en/dataanalysis/monitoringcountryprogress/2010progressreportssubmittedbycountries/haiti_2010_country_progress_report_fr.pdf!








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that!33,123!HIV`positive!adults!were!receiving!ART!at!that!time.1438!However,!according!to!PEPFAR,!ART!coverage!rates!in!2008!were!significantly!lower!for!people!living!with!HIV!in!rural!areas!and!vulnerable!groups,!such!as!commercial!sex!workers!and!men!who!have!sex!with!men,!where!coverage!was!less!than!20%.1439!!According!to!the!WHO,!ART!coverage!for!children!living!with!HIV!was!significantly!lower!than!that!for!the!adult!HIV`positive!population!in!2006.!The!WHO!estimated!that!only!867!HIV`positive!children!under!age!15!were!receiving!ART,!out!of!a!total!6,800!children!living!with!HIV!in!2007.1440!As!such,!childhood!ART!coverage!was!approximately!10%!in!2007.!In!2007,!UNICEF!estimated!the!proportion!of!children!in!need!who!were!receiving!ART!was! far! lower! than!the!WHO!estimate,! suggesting! that!only!300!of! the!6,000!children!in!need!of!ART!(5%)!were!receiving!treatment.1441!!The! 2010! earthquake! severely! disrupted! the! ability! of! people! living! with! HIV! to! access! treatment!services,!especially! in!Ouest,!SudÈst!and!Nippes!Departments!where!57%!of!HIV`positive!Haitians!and!more!than!57%!of!ART!sites!were!located.1442,1443,1444!A!CDC!rapid!assessment!following!the!earthquake!found!that!21%!of!surveyed!sites!within!Portàu`Prince!and!23%!of!surveyed!earthquakeàffected!sites!outside! of! Portàu`Prince! reported! moderate! or! complete! disruption! of! HIV! control! programs.1445!Additionally,!UNAIDS!reported!that! in! the!months! following!the!earthquake,!only!40%!of!people! living!with! HIV! were! accessing! ART! sites.1446! Notably,! this! proportion! reflects! not! only! those! who! were!accessing!ART!services!prior!to!the!earthquake,!but!all!of!those!in!need!of!services.!UNAIDS!attributed!the! low! ART! coverage! rate! to! the! destruction! of! health! facilities,! stockòuts! of! antiretroviral! drugs,!logistical! and! access! challenges,! and! the! overall! damage! suffered! by! the! health! sector.! Positively,!UNAIDS! also! noted! that! service! provision!was! improving! in!many! areas,1447! but! without!more! recent!estimates,!it!is!difficult!to!determine!the!current!status!of!treatment!services!and!coverage.!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1438!Government!of!Haiti,!Rapport'de'situation'nationale'à'l’intention'de'l’UNGASS:'Période'Janvier'20085Décembre(2009!(March!2010).!Available!at!http://www.unaids.org/en/dataanalysis/monitoringcountryprogress/2010progressreportssubmittedbycountries/haiti_2010_country_progress_report_fr.pdf!

1439!PEPFAR,!2008&Country&profile:&Haiti!(2008).!Available!at!http://2006`2009.pepfar.gov/press/81593.htm!1440!WHO,!Epidemiological&fact&sheet&on&HIV&and&AIDS:&Haiti!(December!2008).!Available!at!http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_HT.pdf!!




1444!Global!Health!Council,!Haiti&and&HIV&after&the&earthquake!(March!2010).!Available!at!http://www.globalhealth.org!!

1445!CDC,!CDC&summary&of&initial&rapid&assessment&conducted&by&UN&OCHA&in&Haiti!(February!2010).!1446!UNAIDS,!Helping&Haiti&rebuild&its&AIDS&response!(February!2010).!Available!at!http://data.unaids.org/pub/FactSheet/2010/20100226_haiti_aidsresponse_en.pdf!!


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As! the! HIV! epidemic! in! Haiti! is! driven! by! maternal! transmission,! in! conjunction! with! heterosexual!intercourse,!prevention!of!mother`to`child!transmission!(PMTCT)!is!a!priority!for!the!attenuation!of!the!epidemic.! UNAIDS! underscored! the! importance! of! PMTCT! following! the! January! 2010! earthquake,!stating!that!“(w)ith!an!observed!increasing!trend!of!HIV!among!pregnant!women,!more!children!will!be!born!to!HIV`positive!mothers.”1448!!!Prenatal! HIV! testing! of! pregnant! mothers! is! a! cornerstone! of! successful! PMTCT! programs.! Haiti!experienced!a!dramatic! rise! in!maternal!HIV! testing!over! the! last!decade.!Between!October!2004!and!September!2005,!53,000!pregnant!women!were!screened! for!HIV,1449!while!by! financial!year!2007/08,!141,595!pregnant!women!were!tested.1450!The!2010!Country!Report!to!UNGASS!noted!a!further!increase!in! the! number! of! pregnant!women! tested! in! 2009,!with! 154,835!pregnant!women! tested!during! that!year.1451!However,!UNICEF’s!finding!that!only!59%!of!pregnant!women!were!tested!for!HIV!prior!to!the!earthquake!indicates!the!continued!need!for!expansion!of!access!to!prenatal!HIV!testing.1452!!Although!59%!of!pregnant!women!received!HIV!testing!prior!to!the!earthquake,!a!significantly!smaller!proportion!of!those!in!need!were!able!to!access!PMTCT!treatment.!Estimates!of!PMTCT!coverage!differ!by!source.1453!The!WHO!and!UNICEF!found!that!in!2006,!only!22%!of!HIV`positive!pregnant!women!had!access! to! prenatal! ART,! an! increase! from! 13%! in! 2003.1454,1455,1456,1457,1458! The! Haitian! Government!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1448!UNAIDS,!Helping&Haiti&rebuild&its&AIDS&response!(February!2010).!Available!at!http://data.unaids.org/pub/FactSheet/2010/20100226_haiti_aidsresponse_en.pdf!!



1451!Government!of!Haiti,!Rapport&de&situation&nationale&à&l’intention&de&l’UNGASS:&Période(Janvier(20085Décembre(2009!(March!2010).!Available!at!http://www.unaids.org/en/dataanalysis/monitoringcountryprogress/2010progressreportssubmittedbycountries/haiti_2010_country_progress_report_fr.pdf!








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estimated!this!proportion!to!be!far!lower,!at!10%.1459!By!2008,!the!IMF!reported!that!the!percentage!of!HIV`positive!pregnant!women!receiving!prophylactic!ART!had!increased!to!27%,!or!1,365!women.1460!The!2010! National! Report! to! UNGASS! stated! that! by! 2008,! 48%! of! HIV`positive! pregnant! women! were!receiving!ART!to!prevent!the!risk!of!mother`to`child!transmission.1461!Unfortunately,!the!National!Report!also!noted!that!only!53.9%!of!children!born!to!HIV`positive!mothers!were!enrolled!in!prophylactic!ART!programs!in!2009.1462!!Increases! in!prenatal! treatment!coverage!for!PMTCT!are!attributable!to!both!an! increase! in!treatment!sites!and!to!the!integration!of!HIV!testing!in!antenatal!care!facilities.! In!2003,!only!forty!sites!provided!PMTCT!treatment!services.!By!2007,!there!were!seventy!sites!providing!such!services,1463!while!by!2009,!the!number!of!PMTCT!treatment!sites!had!increased!to!111.1464!The!WHO!estimated!that!in!2006,!100%!of!antenatal!care!facilities!also!offered!HIV!testing!and!counseling.1465!Post`earthquake,!the!provision!of!PMTCT! treatment! services! was! a! priority! for! the! response! community,! and! services! were! quickly!restored!for!all!pregnant!women!previously!receiving!PMTCT!treatment.1466!!As! a! result! of! efforts! to! increase! HIV! testing! among! pregnant!women,! Haitian!women! in! general! are!more!likely!than!their!male!counterparts!to!have!ever!been!tested!for!HIV.1467! In!2006,!18%!of!women!and!11%!of!men!had!been!tested!for!HIV,!a!significant!increase!from!2000!when!only!4%!of!women!and!




1462!Government!of!Haiti,!Rapport&de&situation&nationale&à&l’intention&de#l’UNGASS:#Période#Janvier#20085Décembre(2009!(March!2010).!Available!at!http://www.unaids.org/en/dataanalysis/monitoringcountryprogress/2010progressreportssubmittedbycountries/haiti_2010_country_progress_report_fr.pdf!


1464!Government!of!Haiti,!Rapport&de&situation&nationale!à"l’intention"de"l’UNGASS:"Période"Janvier"20085Décembre(2009!(March!2010).!Available!at!http://www.unaids.org/en/dataanalysis/monitoringcountryprogress/2010progressreportssubmittedbycountries/haiti_2010_country_progress_report_fr.pdf!





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6%!of!men!had!ever!been!tested.1468!Data!from!the!EMMUS!IV!survey!indicated!that!female!youth!aged!20`24!were!more!than!twice!as!likely!to!have!ever!been!tested!for!HIV!than!those!aged!15`19!in!2006,!and!that!those!in!rural!areas!were!less!likely!to!have!been!tested!than!those!living!in!urban!areas!(Figure!98).! Testing! coverage! varied! significantly! among! Departments,! although! coverage! in! all! Departments!was!low.1469!Post`earthquake!estimates!of!testing!coverage!are!unavailable.!!Figure.98:.HIV.testing.among.females.aged.15T24,.by.Department.and.urban/rural.status,.2006.



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Low!rates!of!adolescent!HIV!testing!persist!despite!generally!high!levels!of!HIV!knowledge.1470! In!2006,!the!majority!of!both!urban!and!rural!young!people!aged!15`24!knew!that!abstinence,!having!one!faithful!partner,! and!condoms!were!effective!methods!of!HIV!prevention! (Figure!99).! Young!men!and!women!displayed!similar! levels!of!knowledge,!although!young!girls’!knowledge!of!the!efficacy!of!condoms!was!slightly! lower! than! that! of! their! male! counterparts.1471! Knowledge! of! prevention! methods! was! also!relatively! homogenous! among! young! women! aged! 15`24! across! Departments! (Figure! 100),! although!knowledge!of!the!efficacy!of!condoms!was!lower!than!that!for!limiting!sex!to!one!uninfected!partner!in!all!Departments!but!Grande‘Anse.1472!!!Figure.99:.Knowledge.of.HIV.prevention.methods.among.youth,.by.method,.sex.and.age,.2006.


services&survey!(2006).!Available!at!http://www.measuredhs.com/pubs/pub_details.cfm?id=767&srchTp=home!!!The!proportion!of!Haitian!youth!aged!15`24!who!both!identified!two!preventative!methods!and!rejected!two!misconceptions!about!HIV!transmission!is!significantly!lower,!indicating!that!many!youth!may!retain!incorrect!perceptions,!in!addition!to!correct!information,!regarding!HIV!prevention!methods.!According!to!the!WHO!in!2008,!only!35%!of!youth!both!identified!two!effective!preventative!methods!and!rejected!two!misconceptions,!with!a!higher!proportion!of!young!men!(40%)!displaying!comprehensive!knowledge!than! young!women! (32%).1473!Additionally,! knowledge! that!HIV! could!be! transferred! from!mothers! to!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1470!T.!Dorjgochoo,!F.!Noel,!M.!M.!Deschamps,!et!al.,!“Risk!factors!for!HIV!infection!among!Haitian!adolescents!and!young!adults!seeking!counseling!and!testing!in!Port`au`Prince,”!Journal&of&Acquired&Immune&

Deficiency&Syndromes!52!(2009),!pp.!498`508.!1471!Institut!Haitien!de!l’Enfance,!HIV/AIDS&in&Haiti:&Key&findings&of&the&mortality,&morbidity,&and&utilization&of&




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their!children!during!pregnancy!and!through!breastfeeding!remains!lower!than!knowledge!of!prevention!methods.!In!2000,!68%!of!young!women!knew!that!HIV!could!be!transmitted!during!pregnancy!and!59%!knew!that!HIV!could!be! transmitted! through!breastfeeding.!However,!by!2006,! these!proportions!had!increased! to! 85%! and! 82%,! respectively! (Figure! 101),! indicating! a! significant! diffusion! of! knowledge!about! these! modes! of! transmission.1474! It! remains! unclear! why! these! rates! of! knowledge! have! not!resulted!in!higher!rates!of!prenatal!HIV!testing!and!treatment!for!PMTCT.!!Figure.100:.Knowledge.of.HIV.prevention.methods.among.women.aged.15T24,.by.method,.urban/rural.status,.and.Department,.2006.



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Figure.101:.Knowledge.of.motherTtoTchild.transmission,.by.sex.and.mode.of.transmission,.2000.and.2006.


services&survey!(2006).!Available!at!http://www.measuredhs.com/pubs/pub_details.cfm?id=767&srchTp=home!!!The!impact!of!HIV!infection!extends!beyond!the!individual.!Not!only!do!many!of!those!living!with!HIV!in!Haiti!face!discrimination!and!stigma!both!within!the!family!and!from!others!in!their!community,1475!but!the!families!of!those! living!with!HIV!are!also!often!stigmatized!and!discriminated!against.!Additionally,!many!believe! that! is! the! responsibility!of!organizations,! rather! than! the! community,! to! care! for! those!affected!by!HIV.1476,1477!As!a!result,!families!affected!by!HIV!lack!a!social!safety!net,!and!many!are!forced!to! sell! assets,! withdraw! children! from! school,! send! their! children! to! work,! and! eat! less! to! pay! for!treatment.1478!!The! Haitian! Institute! for! Children! stated! in! 2006! that! “[t]he! full! impact! of! HIV/AIDS! cannot! be!understood! without! examining! the! situation! with! respect! to! orphans! and! other! vulnerable! children!(OVC).”1479! In! 2007,! UNICEF! noted! that! more! than! 200,000! Haitian! children! have! been! orphaned! by!HIV/AIDS,!having!lost!one!or!both!parents.1480!Other!estimates!place!this!number!far!higher.!Using!data!from! 2001,! UNAIDS! estimated! that! there! were! approximately! 259,200! HIV/AIDS! orphans! in! Haiti,! or!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1475!Government!of!Haiti,!Haiti&earthquake&PDNA:&Assessment&of&damage,&losses,&general&and&sectoral&needs!(March!2010).!Available!at!http://siteresources.worldbank.org/INTLAC/Resources/PDNA_Haiti`2010_Working_Document_EN.pdf!



1477!PEPFAR,!2008&Country&profile:&Haiti!(2008).!Available!at!http://2006`2009.pepfar.gov/press/81593.htm!1478!M.!Loudon,!A&study&of&integrated&interventions&for&children&made&vulnerable&by&HIV/AIDS&in&Haiti:&A&case&study&



services&survey!(2006).!Available!at!http://www.measuredhs.com/pubs/pub_details.cfm?id=767&srchTp=home!1480!UNICEF,!UNICEF&humanitarian&action&report&2007!(2007).!Available!at!http://www.unicef.org/har07/index_37587.htm!!

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43.2%!of!the!estimated!600,000!Haitian!orphan!children!in!that!year.1481!A!projection!from!1997!by!the!U.S.! Census! Bureau! similarly! estimated! that! there! would! be! between! 263,000! to! 375,000! HIV/AIDS!orphans!in!Haiti!by!2010.1482!Continued!uncertainty!regarding!the!number!of!HIV/AIDS!orphans!in!Haiti!specifically,!and!orphans!generally,!limits!the!ability!of!decision`makers!to!design!programs!and!policies!addressing!the!needs!of!this!highly!vulnerable!group—a!data!gap!requiring!urgent!attention.!!The! findings! of!many! studies! of! HIV! in! Haiti! have! important! implications! for! programs! and! policy.! In!2008,! for!example,! the! IMF!noted!that!poverty!and!urban!residence! increase!the!risk!of!HIV! infection,!the! latter! association! potentially! due! to! larger! numbers! of! sexual! partners! among! those! in! urban!areas.1483!A!study!of!3391!sexually!active!young!people!attending! the!GHESKIO!clinic! in!Port`au`Prince!found! an! association! between! HIV! infection! and! poor! education! in! females! (but! not! between! HIV!infection!and!marriage!or!childbearing!status),!while!drug!use!and!age!at!sexual!debut!with!a!casual!or!unknown! person! were! important! risk! factors! for! young!men.1484! UNICEF! also! notes! women’s! limited!decision`making! power! in! relationships! as! an! important! contributor! to! the! epidemic,1485! although! the!2006!finding!that!90%!of!women!in!both!urban!and!rural!areas!felt!that!wives!could!ask!husbands!with!STDs! to! use! a! condom! suggests! that! this! power! imbalance!may!be! a! secondary! concern! in! long`term!relationships.1486!Sexual!and!gender`based!violence!following!the!January!2010!earthquake!was!also!of!significant!concern!due!to!the!risk!of!HIV!transmission!during!forced!intercourse!both!within!and!outside!of! displaced! person! camps.1487! The! commitment! of! the! Haitian! Government,! articulated! in! its! Post`Disaster!Needs!Assessment,! to! rebuild!and!expand!HIV! testing!and! treatment! services!establishes!HIV!response!as!a!priority!for!Haiti’s!rejuvenation!which!could!positively!impact!Haitian!children!and!adults!at!both!the!individual!and!community!level.!!!!!






1484!T.!Dorjgochoo,!F.!Noel,!M.!M.!Deschamps,!et!al.,!“Risk!factors!for!HIV!infection!among!Haitian!adolescents!and!young!adults!seeking!counseling!and!testing!in!Port`au`Prince,”!Journal&of&Acquired&Immune&

Deficiency&Syndromes!52!(2009),!pp.!498`508.!1485!UNICEF,!The&state&of&Latin&American&and&Caribbean&children&2008:&Child&survival!(May!2008).!Available!at!http://www.unicef.org/publications/files/SOLAC_2008_EN_041408.pdf!!



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D.&Mental&and&psychologicalLsocial&health&!Very! little!data!exist!on! the!prevalence!of!mental!health!difficulties! in!Haiti,!and! this!Report! found!no!quantitative!studies!on!the!mental!and!psychological`social!(psychosocial)!health!of!children.!Before!the!2010!earthquake,! the!most! comprehensive! review!of!mental!health! in!Haiti!was!one!compiled!by! the!Cultural! Consultation! Service! and! McGill! University! for! the! World! Health! Organization! to! provide! a!context! for! health! relief! operations.! This! review! raises! many! salient! considerations,! including! the!distribution!of!diagnoses!at!a!Portàu`Prince!psychiatric!hospital,! the!causes!and!effects!of!mental!and!psychosocial! illness! in! Haiti,! the! availability! of! and! access! to! care! services,! and! the! importance! of!spiritual! interpretations! of! disorders.1488! However,! population`based! studies! are! sorely! lacking! in! the!mental!health!literature!on!Haiti!and!its!children!and!remain!an!important!area!for!future!research.!!While!prevalence!and!population`based!estimates!are!lacking!for!mental!health,!some!data!are!available!on! the! distribution! of! diagnoses! by! condition! in! Portàu`Prince.! Prior! to! the! 2010! earthquake,! one!hospital! found! that!50%!of!mental!health!diagnoses!were!attributed! to! schizophrenia,!while!a! further!30%! were! associated! with! bipolar! disorder! with! mania,! 15%! with! other! psychoses,! and! 5%! with!epilepsy.1489! These! estimates! were! not! disaggregated! by! age,! and! child`specific! estimates! are!unavailable.!The!Cultural!Consultation!Service!and!McGill!University! literature!review!noted!that!these!proportions! were! not! dissimilar! to! inpatient! diagnoses! in! other! countries,! suggesting! that! diagnosis!reliability!may!not!be!an!issue.!Nonetheless,!it!is!not!possible!to!extrapolate!nationwide!prevalence!rates!from!available!data.1490!!A!2007!study!of!psychological!functioning!of!HIVàffected!youth!and!their!caregivers!by!Smith!Fawzi!et&al.!showed!that!surveyed!youth!experienced!high!levels!of!anxiety,!with!significant!proportions!of!HIVàffected!youth!reporting!symptoms!such!as!constant!fidgeting!(86%),!restlessness!(83%),!and!worrying!a!lot! (56%).1491! Interestingly,! caregivers! of! these! youth! also! reported! very! high! levels! of! depressive!symptoms,! with! 73%! reporting! low! energy,! 71%! feeling! that! everything! is! an! effort,! 69%! reporting!sadness,!43%!having!feelings!of!worthlessness,!and!more!than!19%!admitting!that!they!had!entertained!thoughts!of!ending!their!own!lives.!Caregivers’!symptoms!were!found!to!be!associated!with!those!of!the!children!in!their!care.!Children!with!caregivers!who!displayed!depressive!symptoms!had!approximately!twice! the! risk! of! anxiety,! depression,! anger,! and! loss! of! concentration! than! children! with! other!caregivers.!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1488!Cultural!Consultation!Service,!Mental&health&in&Haiti:&A&literature&review!(February!2010).!Available!at!http://www.state.nj.us/humanservices/dmhs/disaster/MH_in_Haiti%20_Literature_Review.pdf!



1491!M.!C.!Smith!Fawzi,!E.!Eustache,!C.!Oswald,!et!al.,!"Psychosocial!functioning!among!HIVàffected!youth!and!their!caregivers!in!Haiti:!Implications!for!family`focused!service!provision!in!high!HIV!burden!settings,"!AIDS&Patient&Care&and&STDs!24/3!(2010),!pp.!147`158.!

!


As!part!of!their!submission!to!the!Haitian!Government’s!Post`Disaster!Needs!Assessment!following!the!2010!earthquake,!Plan!International!conducted!a!survey!during!January!and!February!of!2010!that!shed!light!on!the!psychosocial!needs!of!Haiti’s!children!and!youth.!This!analysis!revealed!significant!lingering!psychosocial! health! issues! stemming! from! the! earthquake.! Haitian! children! who! had! witnessed! the!death,! injury,! and/or! disability! of! close! family!members! and! friends,! or! had! been! injured! or! disabled!themselves,! listed! psychological! trauma,! grief,! sleeplessness,! and! fear! as! serious! concerns.1492! The!Cultural! Consultation! Service! and!McGill!University! also!noted! that! the! climate!of! insecurity! after! the!earthquake! exacerbated! the! likelihood! of! poor! mental! wellbeing.1493! After! a! shock,! children! are!inherently!more! at! risk! than! other! age! groups! in! the! short! and! long! term! as! they! are! still! physically,!mentally,!and!emotionally!developing.1494!Although!the!methodology!of!Plan!International’s!survey!does!not! allow! for! prevalence! estimation! (as! focus! groups! were! used),! and! it! is! unclear! how! children’s!conditions!have!changed!since!the!assessment,!the!mental!and!psychosocial! impact!of!the!earthquake!on! children,! magnified! by! poor! preèarthquake! conditions,! is! undeniably! a! serious! concern! as! the!country!rebuilds!from!the!devastation!of!the!2010!earthquake.!!!Poor!mental!and!psychosocial!health!in!children!results!in!a!range!of!consequences,!both!for!the!child!in!isolation,! and! as! a! member! of! the! community.! Children! with! compromised!mental! and! psychosocial!health! may! suffer! developmental! delays,! affective! disorders,! behavioral! problems,! and! educational!difficulties.1495! In! 2007,! 51%! of! HIVàffected! youth! reported! that! their! physical! and! mental! health!prevented! them! working,! doing! house! chores,! or! attending! school.! For! 1.8%! of! respondents,! these!problems!occurred!“all!of! the! time.”1496! In!addition,! lack!of!understanding!of!mental!and!psychosocial!health! disorders! among!Haitians!means! that! once!people! have! suffered! repeated!psychotic! episodes,!they!may!be!deemed!“crazy”!for!the!rest!of!their!lives!and!their!judgment!may!never!be!trusted!again.!This! phenomenon!occurs! even! if!medications! reduce! the!psychosis! or! if! long!periods! elapse!between!episodes.!Mental!and!psychosocial!issues!are!therefore!of!great!concern!not!only!to!children,!but!also!to!their! families,!who!may!have! significantly! invested! in! the! child’s! education!and!wellbeing! and! rely!on!that!child!for!their!livelihood,!especially!as!the!child’s!parents!age.1497!!Those! suffering! from! mental! and! psychosocial! concerns! have! few! avenues! to! access! support! and!services!in!Haiti.!Before!the!earthquake,!only!two!public!mental!health!facilities!were!available!in!Haiti,!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1492!E.!Lacroi,!Anticipating&the&future:&Children&and&young&people’s&voices&in&Haiti’s&post5disaster&needs&assessment,!Plan!International!(March!2010).!Available!at!http://planìnternational.org/files/global/haiti`pdna`report.pdf!!






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and!both!were!situated!in!Portàu`Prince.!According!to!PAHO,!while!a!number!of!small,!private!centers!have!opened!outside! the!capital,! the!demand! for!mental!and!psychosocial!health!services! far!exceeds!supply.1498!!Lack!of!both!public!and!private!mental!and!psychosocial!health!services!in!Haiti!compels!the!population!to!seek!alternative!avenues!for!care!and!support.!Although!a!2009!study!by!Nicolas,!Schwartz,!and!Pierre!found! that!most!Haitians! took!pride! in! the!belief! that! they!had! the! inner! strength! to! cope!with!most!obstacles,1499! in! cases! of! overbearing!mental! and! psychosocial! issues,! they!most! frequently! turned! to!their!extended!families!and!traditional!healers!for!support!and!treatment.!Haitians!distinguish!between!‘dépression’,! referring! to! general! discouragement,! and! ‘dépression& mentale’,! which! is! closer! to! the!Western!definition!of!clinical!depression.1500!Desrosiers!and!Fleurose!found!that! individuals!rarely!seek!medical! attention! when! experiencing! depression,! instead! turning! to! their! family! for! assistance.! In!contrast,!dépression&mentale! is!generally!seen!as!either!a!medical!or!spiritual!problem,!and!individuals!often! supplement! their! family`based! care! with! assistance! from! either! a! mental! health! professional!(when!available),!or!a!traditional!healer!(discussed!further!below).1501!!Although! the!extended! family!may!provide!a! supportive!environment! for! those! suffering! from!mental!and!psychosocial!health!concerns,!family!members!are!not!generally!trained!in!psychology!and!medical!sciences,! limiting! their! ability! to! accurately! diagnose! and! manage! the! individual! needing! assistance,!provide!medications! that!may! assist! recovery,! or! avoid!prejudicial! and/or! incorrect! understandings!of!the! illness.! Furthermore,! many! individuals,! especially! young! people,! do! not! feel! that! they! have!somebody! they! can! confide! in!and!draw!on! for! support.! In!2007,!over!22%!of!HIVàffected!youth! felt!that!they!did!not!have!a!confidant!with!whom!they!could!share!their!concerns,!while!almost!40%!of!their!caregivers!felt!they!did!not!have!someone!with!whom!they!could!discuss!their!depressive!symptoms!and!other! aspects! of! their! personal! lives.1502! As! Smith! Fawzi! has! noted,! the! cultural! acceptability! and!propensity! for! those! individuals! with!mental! and! psychosocial! concerns! to! use! their! extended! family!networks!to!access!care!and!support!offers! the!opportunity! for!scaling!up!family`based!approaches!to!care.1503!However,!these!initiatives!would!require!the!reduction!of!stigma!and!misconceptions!regarding!mental! and! psychosocial! health! issues! in! Haiti! to! ensure! access! for! all! individuals.! Moreover,! more!


1499!G.!Nicolas,!B.!Schwartz,!and!E.!Pierre,!"Weathering!the!storm!like!bamboo:!The!strengths!of!Haitians!in!coping!with!natural!disasters,"!in!A.!Kalayjian!and!D.!Eugene!(eds),!Mass&trauma&and&emotional&healing&around&the&world!(Santa!Barbara:!Praeger,!2009).!


1501!A.!Desrosiers!and!S.!St!Fleurose,!“Treating!Haitian!patients:!key!cultural!aspects,”!American&Journal&of&

Psychotherapy!56/4!(2002),!pp.!508`521.!1502!M.!C.!Smith!Fawzi,!E.!Eustache,!C.!Oswald,!et!al.,!"Psychosocial!functioning!among!HIVàffected!youth!and!their!caregivers!in!Haiti:!Implications!for!family`focused!service!provision!in!high!HIV!burden!settings,"!AIDS&Patient&Care&and&STDs!24/3!(2010),!pp.!147`158.!


!


clinical!mental!and!psychosocial!health!services!must!be!established!to!meet!the!mental!health!needs!of!the!population.!!Following! the! 2010! earthquake,! numerous! organizations! have! undertaken! initiatives! to! improve! the!psychosocial!health!of!Haiti’s! children.!Cognizant! that!children’s!early! recovery! from!the!psychological!trauma!of!crises!requires!“1)!the!early!meeting!of!basic!needs,!2)!structured!activities!to!restore!a!sense!of!normality,!and!3)!care!and!nurturing,”1504!World!Vision,!in!the!first!six!months!after!the!earthquake,!established! 22! Child`Friendly! Spaces! (CFS)! to! provide! children! with! safe! spaces! in! which! they! could!engage! in! activities! and! counseling! services.! At! the! time,! many! other! NGOs! were! pursuing! similar!programs.1505! In! April! 2010,! UNICEF! stated! that! 78! CFS’s! had! been! created! nationwide,! with! 55,000!children! benefiting! from! these! and! other! psychosocial! support! activities.1506! By! January! 2011,!UNICEF!reported!that! the!Child!Protection!sub`Cluster!had!established!“369!spaces!offering!more!than!94,800!children!daily!opportunities!to!engage!in!recreational!activities,!access!psychosocial!support,!and!reclaim!their! childhood.”1507! However,! with! all! children! in! Haiti! affected! in! some! way! by! the! earthquake,1508!establishing!opportunities!for!every!one!of!them!to!access!appropriate!forms!of!psychosocial!support!is!a!herculean!endeavor,!and!will!require!far!broader!coverage!than!has!as!yet!been!established!!Any! effective! mental! and! psychosocial! health! activities! for! children! in! Haiti! must! also! recognize! the!important! role! of! spirituality! in! perceptions! of! mental! and! psychosocial! health.! From! a! clinical!perspective,! failure! to!distinguish!between! spiritual!practices!and!psychological!problems!may! lead! to!misdiagnosis!and!mistreatment.1509!From!a!population!perspective,! it! is! important!to!consider!the!role!that! Voodoo! and! traditional! healers! have! historically! played! in! Haitians’! perception! of! physical! and!mental! health.! Desrosiers! and! St.! Fleurose! have! noted! that! the! vast!majority! of! Haitians! believe! that!mental! illness! is! caused! by! supernatural! phenomena,! and! that! depression,! psychosis,! poor! school!performance,!and!other!symptoms!may!all!be!seen!as!consequences!of!a!spell!or!curse.1510!Most!Haitians!will! first! seek!help!outside!of! the! family! from!a!Houngan,! a!male!Voodoo!priest,! and!will!usually!only!seek!the!help!of!a!mental!health!professional!if!numerous!visits!to!a!Houngan!have!failed!to!successfully!


1505!World!Vision,!A&call&to&Action:&Haiti&at&6&months!(June!2010).!Available!at!http://www.worldvision.com.au/Libraries/HEA_reports/A_Call_to_Action_`_Haiti_at_6_months.sflb.ashx!!


1507!UNICEF,!Children&in&Haiti:&One&year&after&–&the&long&road&from&relief&to&recovery!(January!2011).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/10CF91515919332F49257811001C26F3`Full_Report.pdf!


1509!M.!Azaunce!(1995),!cited!in!Cultural!Consultation!Service,!Mental&health&in&Haiti:&A&literature&review!(February!2010).!Available!at!http://www.state.nj.us/humanservices/dmhs/disaster/MH_in_Haiti%20_Literature_Review.pdf!

1510!A.!Desrosiers!and!S.!St!Fleurose,!“Treating!Haitian!patients:!key!cultural!aspects,”!American&Journal&of&

Psychotherapy!56/4!(2002),!pp.!508`521.!

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address!the!issue.1511,1512!Some!Haitians!seeking!mental!and!psychosocial!treatments!will!simultaneously!use! a!mental! health! practitioner! and! a!Houngan.! The! likelihood! of! seeking! a!Houngan! rather! than! a!mental! health! professional! is! associated! with! socioeconomic! status.! Those! in! the! upper! and! middle!classes!are!more! likely! to!access!mental!health!services,! rather! than! traditional!healers,! than! those!of!lower! socioeconomic! status.1513! Denominational! spirituality! is! also! considered! important! in! Haitian’s!sense!of!healing.!A!survey!of!Haitian!migrants!in!the!United!States!found!that!Haitians!were!more!likely!to!report!that!prayer! is! important!to!overcome!difficult!situations!than!migrants!from!other!Caribbean!countries,!even!after!accounting!for!differences!in!denomination.1514!With!the!overwhelming!majority!of!Haitians! practicing! varying! forms! of! Christianity,! Voodoo! and! Christianity! should! not! be! seen! as!competing!belief!systems,!but!rather!as!complementary.!!!Mental!health!has!not!been!a!priority!for!policymakers,!educators,!and!service!providers!in!Haiti.!Lack!of!a!national!mental!health!policy!has!resulted!in!a!lack!of!service!planning,!chronic!underìnvestment,!and!inadequate!training.!In!2003,!PAHO!estimated!that!there!were!only!ten!psychiatrists!and!nine!psychiatric!nurses!in!the!public!sector!across!Haiti,!and!most!worked!in!Portàu`Prince.1515!The!Cultural!Consultation!Service!and!McGill!University!also!noted!that!of!the!two!psychiatric!hospitals! in!Portàu`Prince,!one!of!them!was!dilapidated!even!prior!to!the!January!2010!earthquake.!The!entire!north!of!Haiti!is!serviced!by!a! monthly! visit! by! one! psychiatrist! from! Portàu`Prince.! Historical! lack! of! training! of! mental! health!professionals!in!Haiti!and!lack!of!funding!for!training!and!service!provision!raise!serious!concerns!for!the!long`term!mental!health!of!Haitians,!especially! in! light!of!the!overwhelming!impact!of!the!earthquake,!coupled!with!endemic!unmet!need!Haiti`wide.1516!To!appropriately!provide! for!Haitian!children’s! long`term!psychosocial!health,!sustainable!systems!of!mental!health!care!are!essential.!!!

E.&Drug&use&!In!2000,! the!Haitian!Government! found! that!many!secondary!school! students!considered!accessing! to!drugs! to!be!“easy”,!with! results!varying!by!drug! type.! In! fact,!98%!of! students! said! they!believed! that!cigarettes!were!easy!to!obtain,!while!97%!believed!the!same!to!be!true!for!alcohol.!More!worrisome!is!the! percentage! of! students! reporting! that! access! to! controlled! or! banned! substances!was! easy,! with!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1511!A.!Desrosiers!and!S.!St!Fleurose,!“Treating!Haitian!patients:!key!cultural!aspects,”!American&Journal&of&

Psychotherapy!56/4!(2002),!pp.!508`521.!1512!Cultural!Consultation!Service,!Mental&health&in&Haiti:&A&literature&review!(February!2010).!Available!at!http://www.state.nj.us/humanservices/dmhs/disaster/MH_in_Haiti%20_Literature_Review.pdf!


1514!L.!M.!Chatters,!J.!R.!Taylor,!J.!S.!Jackson,!and!K.!D.!Lincoln,!“Religious!coping!among!African!Americans,!Caribbean!blacks!and!non`Hispanic!whites,”!Journal&of&Community&Psychology!36/3!(2008),!pp.!371`386.!



!


72%,! 39%! and! 31%,! respectively,! saying! that! they! believed! analgesics,! tranquilizers,! and! inhalants!(including!paint!thinner)!could!be!easily!obtained.1517!!!In!2005,!the!Haitian!Government’s!National!Commission!on!the!Fight!against!Drugs!interviewed!school!children! to! determine! the! prevalence! of! drug! use! (Figure! 102).! Almost! 11%! of! respondents! reported!having!smoked!in!their!lifetime,!with!1.8%!reporting!to!have!smoked!during!the!past!month.!Boys!were!more! likely! to! report! trying! cigarettes,! with! 13.8%! reporting! smoking! in! their! lifetime,! compared! to!10.9%! of! girls.! Similarly,! boys! were! more! likely! to! have! drunk! alcohol! (58.8%)! than! girls! (48.7%).!However,!the!use!of!tranquilizers!and!stimulants!(including!marijuana,!cocaine,!solvents,!cocaine!paste,!sleeping!pills,!and!other!drugs)!was!higher!among!girls!than!boys,!with!29.6%!of!girls!having!ever!tried!tranquilizers! and! 24.4%! trying! stimulants,! compared! to! 26.1%! of! boys! trying! tranquilizers! and! 21.4%!having!ever!tried!stimulants.1518!In!2000,!PAHO!noted!that!among!students!using!marijuana,!boys!started!using! later! than! girls,! with! boys! starting! at! an! average! age! of! 17! compared! with! girls! starting! at! an!average!age!of!11.1519!Overall,!lifetime!drug!use!among!secondary!students!is!concentrated!in!relatively!few!Departments,! particularly! in! Ouest,! Nord,! and! Sud! Departments,!with! far! lower! rates! in! Sud`Est,!Artibonite,!Centre,!Grande’Anse,!Nord`Est,!and!Nippes!Departments.!Troublingly,!the!survey!found!that!the! primary! reason! students! cited! for! using! drugs! was! “to! try! to! forget! the! problems! they! face.”1520!Efforts!targeting!drug!use!reduction!must!therefore!be!contextually!situated!against!a!backdrop!in!which!many! young! people! feel! that! their! troubles! drive! them! to! find! an! escape,! with! substance! abuse!providing!such!an!outlet.!Additionally,!60%!of!surveyed!students!had!not!participated!in!a!class!at!school!on!drugs,!and!45%!are!not!informed!of!their!deleterious!health!and!social!consequences,!increasing!the!probability!that!young!people!may!become!users!of!illicit!substances.1521!!!!!!!!


1518!Haitian!National!Commission!on!the!Fight!Against!Drugs,!Drug&prevalence&survey&of&secondary&school&students&in&Haiti,&2005!(August!2007).!Available!at!http://www.cicad.oas.org/oid/caribbean/2007/HAITI%20SCHOOL%20SURVEY.pdf!




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Figure.102:.Prevalence.of.drug.use,.by.substance,.time.period,.and.gender,.2005.

Used in: Cigarettes Alcohol Tranquilizers Stimulants

M F Total M F Total M F Total M F Total Lifetime 13.8 8.4 10.9 58.8 48.7 53.4 26.1 29.6 28 21.4 24.4 23

Past year 5.6 2.4 3.9 36.8 26.9 21.5 12.2 15.5 13.9 9.6 12.2 11 Past

month 2.7 1.1 1.8 24.3 17.7 20.8 7.5 9.7 8.7 5.9 8.2 7.1

Data!source:!Haitian!National!Commission!on!the!Fight!Against!Drugs,!Drug&prevalence&survey&of&secondary&school&students&in&Haiti,&2005!(August!2007).!Available!at!http://www.cicad.oas.org/oid/caribbean/2007/HAITI%20SCHOOL%20SURVEY.pdf!

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8.&Education&&!The!Haitian!Constitution!of!1987!guarantees!the!right!of!all!Haitian!citizens!to!nine!years!of! free!basic!education,! including! the! costs! of! textbooks! and! other! didactic!material.! In! reality,! barriers! to! access,!including!unavailability!of!classroom!seats,!the!widespread!requirement!of!school!fees,!and!geographical!factors! that! negate! access! for! many! mean! this! right! is! far! from! being! universally! realized.! Although!education!and!literacy!are!held!in!high!esteem!in!Haiti,!many!Haitians!express!concern!that!they!or!their!children!will! be!unable! to! attain! a! level! of! qualification! that!will! improve! future!opportunities.1522! For!many,!formal!education!is!a!luxury!beyond!reach,!while!for!others,!physical!and!financial!barriers!require!significant!sacrifice!with!uncertain!dividends.!Far!from!being!guaranteed,!education!in!Haiti!thus!remains!a!privilege!that!many!cannot!afford.!!Haiti’s!education!system!is!characterized!by!a!litany!of!shortcomings!that!limit!its!ability!to!increase!the!human!capital!of!the!country’s!population.!Returns!to!both!private!and!public!investment!in!education!are! low,! while! exclusionary! and! fragmented! access! to! quality! education! perpetuates! inequality! and!offers!little!opportunity!for!social!mobility!and!advancement.!Similarly,!inadequate!structural!reform!and!the!discrepancy!between! legislation,!policy,! and! the! reality! result! in!high!drop`out! rates! and! ratios!of!over`aged!students.!!To!assess!education!in!Haiti,!this!Report!begins!by!considering!the!country’s!early!childhood!education!system!available! to!a! subset!of! children!before! they!enter! the!official!education! system.! It! then!more!closely!examines!the!structure!and!composition!of!the!formal!education!system!and!the! impact!of!the!January!2010!earthquake!on!this!system.!It!goes!on!to!explore!Haitians’!engagement!with!the!education!system!and!how!this!engagement!translates!into!country`level!outcomes!for!education!quality.!Finally,!it!assesses! barriers! to! educational! access! and! identifies! specific! factors! that! undermine! the! quality! of!schooling!and!training!in!Haiti.!!!

A.&Early&childhood&care&and&education&!Early! childhood! education! is! instruction! in! the! period! before! primary! school! that! enables! children! to!transition!from!the!family!to!school!environment.!Its!role!is!to!introduce!children!to!both!the!modalities!of!learning!they!will!experience!in!later!years!and!provide!the!foundational!skills!for!later!achievement!in!their!schooling.!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1522!H.!Lunde,!Youth&and&education&in&Haiti:&Disincentives,&vulnerabilities&and&constraints,!Fafo!paper!2008/26!(2008).!Available!at!http://www.fafo.no/pub/rapp/10070/10070.pdf!!

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In! Haiti,! children! are! eligible! for! early! childhood! education,! which! officially! lasts! for! three! years,!beginning! at! age! three.1523! The! Pre`School! Education! Management! Bureau,! within! the! Ministry! of!Education,!is!the!body!primarily!responsible!for!supervising!and!coordinating!Haiti’s!early!childhood!care!and!education! (ECCE)!programs.1524!However,! the!vast!majority!of!pre`schools!are!not!public.! In!2000,!UNESCO!stated!that!approximately!83%!of!pre`schools!were!privately!operated,!with!only!280!of!1,680!pre`schools! provided!by! the! public! sector.1525! In! contrast,! the! 2009!National! Policy! Framework! for! an!Integrated!Approach!to!Early!Childhood!Development!(DIPE)!stated!that!only!5.5%!of!Haitian!pre`schools!were!publicly!supported,!serving!only!4.67%!of!Haiti’s!595,000!preschoolers.1526!Private!pre`schools!are!provided!by!a!range!of!groups,!including!religious!organizations,!NGOs,!international!organizations,!and!private!schools!that!offer!later!primary!grades.1527!Despite!the!fact!that!most!Haitian!children!live!in!rural!areas,!most! early! childhood!education! facilities! are! located! in! urban! areas,! resulting! in! children! living!outside!cities!and!towns!being!disenfranchised.1528!!Estimates! of! Haiti’s! pre`primary! gross! enrollment! ratio! (GER)! (the! total! enrollment! in! pre`primary!education,! regardless!of! age,! expressed!as!a!percentage!of! the!eligible!official!pre`primary! school`age!population!in!a!given!school!year)1529!differ!by!source,!although!all!reflect!a!significant!upward!trend!in!enrollment!over!the!past!two!decades.!The!Haiti!Country!Report!to!UNESCO’s!2000!Education!for!All!in!the! Caribbean! report! noted! that! in! 1990,! Haiti’s! pre`primary! GER!was! 20.7%,! increasing! to! 44.6%! by!1995,!and!continuing! to!64.3%! in!1997.1530! In!2006,!UNESCO!concluded! that!Haiti’s!GER!was!19.7%! in!1990,! and! increased! to! only! 45%! by! 2000.1531! Data! from! the! 1997! census! indicate! that! in! that! year,!Haiti’s!GER!had!reached!63%.1532!Using!statistics!provided!by!the!Ministry!for!Education!and!Professional!



1524!UNESCO,!Haiti:&Early&childhood&care&and&education&(ECCE)&programmes,!UN!Doc.!IBE/2006/EFA/GMR/CP/36!(2006).!Available!at!http://unesdoc.unesco.org/images/0014/001480/148026e.pdf!!



development!(January!2009).!!1527!B.!Hadjadj,!Education&for&all&in&Haiti&over&the&last&20&years:&Assessment&and&perspectives,!UNESCO!Education!for!all!in!the!caribbean:!Assessment!2000!monograph!series!No.!18!(2000).!Available!at!http://unesdoc.unesco.org/images/0013/001363/136393e.pdf!


1529!UNESCO,!Education&indicators:&Technical&guidelines,!UNESCO!Institute!for!Statistics!(November!2009).!Available!at!http://www.uis.unesco.org/Library/Pages/default.aspx!!

1530!V.!Jules!and!A.!Panneflek,!Subregional&synthesis&report:&Volume&I&5&Summary,!Education!for!all!in!the!Caribbean:!Assessment!2000!(2000).!Available!at!http://www.unesco.org/carneid/synthesis`1.pdf!


1532!B.!Hadjadj,!Education&for&all&in&Haiti&over&the&last&20&years:&Assessment&and&perspectives,!UNESCO!Education!for!all!in!the!caribbean:!Assessment!2000!monograph!series!No.!18!(2000).!Available!at!http://unesdoc.unesco.org/images/0013/001363/136393e.pdf!

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Formation,!Wolff!concluded!that!Haiti’s!pre`primary!GER!in!2007!was!67%,!indicating!little!increase!over!the!preceding!seven!years.1533!!In! contrast! to! its! pre`primary! GER,! Haiti’s! pre`primary! Net! Enrollment! Ratio! (NER)! reveals! that! most!children! attending!pre`primary! education! are!not! in! the! correct! official! year! for! their! age.! The!NER! is!defined!as!“enrolment!of!the!official!age`group!for!a!given!level!of!education!expressed!as!a!percentage!of!the!corresponding!population.”1534!As!such,!unlike!the!GER,!the!NER!includes!only!those!children!who!are! the!official! age! for! the! level! of! education! in!which! they! are! enrolled.! Figure! 103! indicates! that! in!2006,!only!58.18%!and!58.58%!of!boys!and!girls!in!the!first!year!of!pre`primary!education,!respectively,!were!three!years!old.!The!proportion!of!students! in! the!correct!school!year! for! their!age!continues! to!decline! as! pre`primary! grade! increases,!with! approximately! 44%! of! second`year! students! and! 33%! of!third`year!students!the!correct!age!for!their!school!level.!Significantly,!seven!year!old!students!make!up!a! larger!proportion!of! the!total! third!year! (“third!grade”)!pre`primary!enrollment! (approximately!37%)!than!do!children!of!the!correct!age!for!that!level.1535!As!discussed!further!in!this!section,!completion!of!pre`primary! education! is! often! used! as! a! screening! tool! for! admittance! into! the! first! year! of! primary!education! as! schools! devise! ways! to! allocate! scarce! school! places! to! the! overwhelming! number! of!applicants.!The!large!proportion!of!children!who!are!older!than!the!official!age!for!the!third!year!of!pre`primary! education!may! therefore! be! seen! as! the! result! of! high! repetition! rates,! late! enrollment,! and!barriers!of!entry!to!the!first!year!of!primary!school.!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1533!L.!Wolff,!Education&in&Haiti:&The&way&forward,!Partnership!for!Educational!Revitalization!in!the!Americas!(PREAL)!(September!2008).!Available!at!http://www.thedialogue.org/PublicationFiles/Education%20in%20Haiti%20`%20The%20Way%20Forward%20`%20FINAL%20`%209`15`08.pdf!!

1534!UNESCO,!Net&enrollment&ratios!(2011).!Available!at!http://glossary.uis.unesco.org/glossary/en/home!!1535!UNESCO,!Haiti:&Early&childhood&care&and&education&(ECCE)&programmes,!UN!Doc.!IBE/2006/EFA/GMR/CP/36!(2006).!Available!at!http://unesdoc.unesco.org/images/0014/001480/148026e.pdf!!

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Figure.103:.Breakdown.of.preTschool.pupils,.by.gender,.section,.and.age,.2006.

!Source:!UNESCO,!Haiti:&Early&childhood&care&and&education&(ECCE)&programmes,!UN!Doc.!IBE/2006/EFA/GMR/CP/36!(2006).!Available!at!http://unesdoc.unesco.org/images/0014/001480/148026e.pdf!!

!!Insufficient!supply!of!teachers!and!prohibitive!costs!are!disincentives!for!children!to!attend!pre`primary!education! at! any! level.! In! 1998`1998,!UNESCO! found! that! there!were! 12,236! pre`primary! teachers! in!Haiti,!yielding!an!average!class!size!of!34!children!per!teacher.!The!2009!national!DIPE!framework!stated!that! there!were! 20,000! pre`school! teachers! operating! in! Haiti! at! that! time,! and! that! teacher`student!ratios! ranged! from! 1:20! to! 1:40! per! class.! Of! these! 20,000!Haitian! pre`school! teachers,!most! did! not!possess!appropriate!qualifications.1536!!It! is! likely!that!class!sizes!vary!significantly!depending!on!the!school!and! its! fees.! In!2006,! fees!for!one!year!of!pre`primary!education!ranged!from!50!to!5,000!gourdes!(US$1.25!`!$125).1537!The!cost!of!sending!children! to! high! quality! pre`primary! education,!where! it! is! likely! that! class! sizes! are! smaller,! places! a!considerable!strain!on!household!budgets,!disenfranchises!the!poor,!and!consolidates!inequality!due!to!a!lack!of!access!as!well!as!lower!expected!returns!stemming!from!larger!class!sizes.1538!!Despite! these! barriers! to! utilization,! post`earthquake! data! suggest! that! Haitian! parents! place! a! high!degree! of! importance! on! pre`primary! education.! Second! only! to! nutrition! programs! (81%),! 13%! of!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1536!Government!of!Haiti,!2009&national&policy&framework&for&an&integrated&approach&to&early&childhood&

development!(January!2009).!1537!UNESCO,!Haiti:&Early&childhood&care&and&education&(ECCE)&programmes,!UN!Doc.!IBE/2006/EFA/GMR/CP/36!(2006).!Available!at!http://unesdoc.unesco.org/images/0014/001480/148026e.pdf!!


development!(January!2009).!

!


surveyed! parents! identified! preschool! as! the! top! priority! for! children! aged! 1`4,! while! a! further! 29%!identified! preschool! as! the! second! most! important! priority! for! this! age! group.! As! such,! 42%! of!respondents!after!the!earthquake!identified!pre`primary!education!as!either!their!first!or!second!priority!for! children!aged!1`4,!highlighting! the!perceived! importance!of!early! childhood!care!and!education! in!Haiti.1539!!Relief! distributions! in! the! five!months! following! the! January! 12! earthquake,! however,! did! not! reflect!these! priorities.! A! survey! conducted! by! Global! Relief! Technologies! for! USAID! found! that! 92%! of!households!lacked!any!play!materials!for!their!children,!with!only!1%!reporting!that!all!of!their!children!had! access! to! play! materials,! and! 7%! reporting! access! for! some! of! their! children.! Similarly,! 65%! of!households!stated!that!none!of!their!children!had!access!to!learning!materials,!although!18%!reported!access! for!all!of! their!children,!and!17%!cited!access! for!some!children! in!the!household.1540!By!March!2011,! the! Education! Cluster! reported! that! 850,000! children! had! benefited! from! the! distribution! of!learning!materials,1541!more! than! three! times! the! number! who! had! benefited! from! learning!material!distributions!(266,844!children)!at!the!beginning!of!September!2010.1542!!!!

B.&Formal&education&system&!Haitian!children!are! legally!admissible!to!primary!education!at!age!6.!Primary!education! is!compulsory!(though!unenforced)!and!divided!into!nine!years,!while!non`compulsory!secondary!education!comprises!a! further! four! years.! As! such,! primary! and! secondary! education! should! take! 13! years,! and! students!should!graduate!at!age!18!or!19!(Figure!104).!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1539!Haiti!Education!Cluster,!Education&cluster&rapid&joint&needs&assessment&(RJNA):&RJNA&final&report!(March!2010).!Available!at!http://oneresponse.info/Disasters/Haiti/Education/Documents/RJNA%20Report%20ENGLISH.docx!!

1540!Global!Relief!Technologies,!Haitian&field&assessments:&US&Agency&for&International&Development&weekly&data&

analysis&for&the&week&of&June&14,&2010!(June!2010).!1541!Global!Education!Cluster,!Global&education&cluster&update:&January&5&March&2011,!Global!Education!Cluster!(2011).!Available!at!http://oneresponse.info/GlobalClusters/Education/publicdocuments/Education%20Cluster%20Update_January_March_2011_FINAL.pdf!

1542!UN!OCHA!Haiti,!Haiti:&Humanitarian&indicator&and&presence&report!(September!2010).!Available!at!http://oneresponse.info/Disasters/Haiti/Education/publicdocuments/education_dashboard_ENG.pdf!

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Figure.104:.Structure.of.the.Haitian.education.system.

!Source:!Haitian!Ministry!of!Education,!Youth!and!Sports,!The&problem&of&over5age&students&in&the&Haitian&education&


!!The! nine! years! of! primary! education! are! sub`divided! into! three! cycles.! The! first! cycle! encompasses!grades!1–4,!the!second!grades!5!and!6,!and!the!third!grades!7`9.!“Basic!education”!refers!to!grades!1`6!(the! first! two! cycles).1543! According! to! Haiti’s! official! education! plan,! Plan& National& d’Education& et& de&Formation!(PNEF),!progression!within!each!of!the!primary!education!cycles!should!occur!automatically.!However,!students!are!required!to!pass!national!examinations!at!the!end&of!each!cycle!to!be!eligible!to!proceed!to!the!next!cycle!(though,!in!practice,!many!students!sit!exams!at!the!end!of!each!level!and!do!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1543!B.!Hadjadj,!Education&for&all&in&Haiti&over&the&last&20&years:&Assessment&and&perspectives,!UNESCO!Education!for!all!in!the!caribbean:!Assessment!2000!monograph!series!No.!18!(2000).!Available!at!http://unesdoc.unesco.org/images/0013/001363/136393e.pdf!

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not! progress! automatically.! See! Section!8E.& Access& to& education& and& barriers& to& enrollment).! As! such,!students!are!required!to!sit!a!national!exam!at!the!end!of!their!4th,!6th!and!9th!years.1544!!!Successful! completion! of! primary! school! qualifies! students! to! attend! secondary! school,!which! in! turn!qualifies! them! to! attend! university! and! professional! training.! To! attend! university,! Teacher! Training!College,!or!some!technical!and!vocational!education!centers,!students!must!have!completed!all!13!years!of! primary! and! secondary! education.! As! Lund! has! noted,! this! requirement! places! higher! education!outside! the! reach! of!most!Haitian! young! people! (See! Section!8E.& Access& to& education& and& barriers& to&enrollment).1545!!Technical! and! vocational! education! can! be! disaggregated! into! three! groups:! Technical! Education!Institutes,!Vocational!Education!Schools,!and!Skill!Training!Centers.!Technical!Education!Schools!require!entrants!to!have!completed!both!primary!and!secondary!education,!and!are!thus!inaccessible!for!most!young! people.! Vocational! Education! Schools! require! the! completion! of! the! second! cycle! of! primary!education! (6th! grade)! and! provide! more! practically`oriented! training.! Skill! Training! Centers! are! the!largest!of!the!three!groups,!and!many!do!not!require!any!prior!education.!However,!the!vast!majority!of!these!Centers!are!privately!operated!and!unregulated!by!the!Haitian!government,!raising!concerns!over!both!equity!and!quality.1546!!The!Haitian!government’s!Post`Disaster!Needs!Assessment!highlighted!the!two!primary!shortcomings!of!technical!and!vocational!education! in!Haiti.! Fundamentally,! there! is!an!overwhelming!absence!of,!and!lack!of!adherence!to,!regulation!governing!the!offering!and!curricula!of!practical!training!courses,!such!that! available! educational! opportunities! do! not! fit! the! country’s! development! needs.! Secondly,!management! of! training! programs,! conducted! by! eight! different! ministries,! is! fragmented! and!uncoordinated.! These! factors! result! in! a! situation! in! which! even! students! eligible! to! participate! in!vocational!and!technical!education! lack!the!skills! required!for!gainful!employment!and!participation! in!Haiti’s!development,!as!their!skills!are!not!aligned!with!the!needs!of!the!employment!market!or!national!development!priorities.1547!!Compounding! the! challenge! is! the! dislocation! of! legislation! and! policy! from! the! situation! “on! the!ground.”!The!Haitian!government!itself!is!aware!of!this!discrepancy,!stating!in!2000!that!the!admission!requirements!for!schooling!set!forth!in!relevant!legislation!“are!merely!theoretical!and!do!not!reflect!the!






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current! reality! of! the! system.”1548! Though! referring! to! students’! progression! through! primary! and!secondary!school,!the!same!sentiment!is!true!for!two!other!major!aspects!of!the!education!system:!the!primary! and! secondary! school! curricula—which! are! too! long! and! impractical! for! the! overwhelming!majority!of!Haitian!children,!discouraging!and!severing!access!from!further!training!and!opportunities—and! the! state’s! inability! to! fulfill! its! Constitutional! obligation! to! provide! free! primary! education.1549!Within!the!current!system,!students!can!access!few!gainful!educational!opportunities!before!completing!an!intermediate!level!of!education.!At!present,!this!level!of!attainment!is!outside!of!the!reach!of!many!young!Haitians.!The!lack!of!alternative!intermediate!educational!paths!limits!children’s!ability!to!acquire!skills!that!equip!them!to!contribute!to!their!community,!instead!requiring!a!drawn`out!period!of!tuition!that!few!can!afford.!!!UNICEF! reports! that! there! were! approximately! 22,000! schools! in! Haiti! prior! to! the! January! 2010!earthquake,1550!more! than!double! the! 9,528!present! in! 1996/1997.1551!However,! extrapolation!of! two!factors!suggests!that!most!of!these!schools!did!not!teach!up!to!or!past!the!second!cycle.!The!increase!in!the! number! of! schools! over! the! past! 30! years! has! largely! been! attributable! to! the! establishment! of!private! schools! that! operate! outside! of! government! regulation! (discussed! in! further! detail! below).1552!Additionally,! these! private! schools! generally! teach! only! the! first! cycle,! requiring! students! to! change!schools!to!continue!their!education.!Between!1980/81!and!1996/97,!the!proportion!of!schools!teaching!the!first!two!cycles!of!primary!education!(grades!1!to!6)!fell!from!63%!to!50%.1553!As!the!increase!in!the!number!of!schools!in!Haiti!has!continued!to!be!driven!by!the!founding!of!private!schools,!it!is!likely!that!the!proportion!of!schools!offering!at!least!the!first!two!cycles!of!primary!education!has!continued!to!fall,!illustrating! one! of! many! systemic! bottlenecks! preventing! investment! in! the! country’s! young! human!capital.!!Various! studies!and! reports!have! revealed! the! inadequacy!of!governance!and!oversight!of! the!Haitian!educational! system.1554! A! 2004! review!by! the!Haitian! government! and! the! international! development!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1548!Haitian!Ministry!of!Education,!Youth!and!Sports,!The&problem&of&over5age&students&in&the&Haitian&education&








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community,! for! example,! highlighted! the! inability! of! the! Ministry! of! National! Education,! Youth! and!Sports!(MENJS)!to!fulfill! its!mandated!regulatory!role!due!to!“weak!strategic!capacity,!outdated!vision,!limited!steering!ability,! lack!of! institutional!memory,! insufficient!inspection!and!lack!of!transparency!in!the! allocation! of! finances! outside! of! salaries! for! the! start! of! the! school! year,”! as! well! as! the! lack! of!dialogue! between! the! Ministry! and! the! private! sector.1555,1556! The! report! added! that! the! structural!inadequacy! of! the! Haitian! education! system,! due! in! part! to! the! lack! of! government! capacity,! has!constrained!the!state’s!ability!to!invest!in!the!human!capital!of!the!younger!generation,!resulting!in!poor!outcomes!for!both!young!people!themselves!and!the!country!as!a!whole.!!The!proliferation!of!private!schools!is!both!a!cause!and!an!outcome!of!the!state’s!inability!to!provide!for!the!education!needs!of! its!children.!On!the!eve!of!the!January!2010!earthquake,!only!8%!(1,241)!of!all!primary! and! secondary! schools! in! Haiti! were! state! schools,! while! the! remaining! 92%! (14,027)! were!privately!operated,!most!without!any!financial!assistance!from!the!state.1557,1558,1559,1560,1561,1562,1563,1564!As!a!result,!approximately!80%!(1,716,187)!of!all!students!in!Haiti!(2,106,805)!were!educated!in!fee`based,!non`public! schools! (Figure! 105).1565,1566,1567,1568,1569,1570,1571,1572! In! 2006,! Haiti! was! the! only! one! of! the!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1555!Government!of!Haiti,!Interim&cooperation&framework&200452006:&Summary&report!(2004).!Available!at!http://haiticci.undg.org/uploads/ReportVersion8%20Eng%20FINAL%20Low%20Res.pdf!!


development!(January!2009).!1557!World!Bank,!Social&resilience&and&state&fragility&in&Haiti:&A&country&social&analysis,!Caribbean!Country!Management!Unit,!Report!no.!36069`HT!(April!2006).!Available!at!http://siteresources.worldbank.org/SOCIALANALYSIS/1104894`1115795935771/20938696/Haiti_CSA.pdf!


1559!H.!D.!Nielsen,!Moving&towards&free&primary&education:&Policy&issues&and&implementation&challenges&5&A&state&of&











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world’s!twenty!poorest!countries!where!more!than!50%!of!children!attend!non`state!schools.1573!Private!school!fees!are!predominantly!financed!by!parents,!religious!organizations,!and!NGOs.!Lunde!notes!that!one!consequence!of!this!privatization!of!education!is!that!“private!households!are!carrying!the!economic!burden!of!both!the!real!cost!of!education!and!the!private!actors’!profit.”1574!Troublingly,!at!least!75%!of!private!primary! schools! in!Haiti! reportedly! do!not! have! the! required! license! to!operate! a! school,! and!therefore! operate! outside! of! government! regulation.1575,1576! The! Haitian!Ministry! of! Education,! Youth!and! Sports! notes! that! it! is! the! proliferation! of! these! non`accredited! private! schools! that! causes! the!majority! of! issues! within! the! education! system! as! a! whole,! including! high! rates! of! repetition,! early!departure,!and!operation!below!minimum!standards!of!quality.1577,1578!However,!it!is!the!inability!of!the!government! to! provide! accessible! education! that! has! created! a! market! for! private! schools! and!complicates!the!state’s!efforts!to!enforce!its!central!management!and!coordination!responsibility.1579,1580!Despite!the! limitations!caused!by!a!private!sector`dominated!educational!system,!the!government!has!determined!that!there!is!no!other!viable!alternative!to!reach!Haiti’s!children,!and!maintains!that!private!schools!have!a!lower!unit!cost!and!are!more!accountable!to!children’s!families!than!public!schools.1581!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1569!H.!D.!Nielsen,!Moving&towards&free&primary&education:&Policy&issues&and&implementation&challenges&5&A&state&of&








1576!J.!Salmi,!“Equality!and!quality!in!private!education:!The!Haitian!paradox,”!Compare:&A&Journal&of&Comparative&

Education!30/2!(2000),!pp.!163`178.!1577!Haitian!Ministry!of!Education,!Youth!and!Sports,!The&problem&of&over5age&students&in&the&Haitian&education&







!


Figure.105:.Educational.enrollment,.by.public/private.status,.2006.(estimated).

!Source:!L.!Wolff,!Education&in&Haiti:&The&way&forward,!Partnership!for!Educational!Revitalization!in!the!Americas!(PREAL)!(September!2008).!Available!at!http://www.thedialogue.org/PublicationFiles/Education%20in%20Haiti%20`%20The%20Way%20Forward%20`%20FINAL%20`%209`15`08.pdf!!

!!Reliance!on!private`sector!provision!of!education!has! led!to!a!unique!situation!whereby!Haitian!public!education!expenditure!is!among!the!lowest!in!the!world!as!a!proportion!of!GDP,!while!private!education!expenditure! is! among! the! highest.! In! 2006,! the! Haitian! government! allocated! approximately! US$83!million! to! education,! representing! 1.97%! of! the! country’s! GDP,! approximately! US$41! per! student.! In!contrast,!private!spending!accounted!for!more!than!three!times!this!figure,!at!US$276!million,!or!6.57%!of! GDP.! As! such,! roughly! 8.54%! of! Haiti’s! GDP!was! directed! towards! education! in! 2006.! It! should! be!noted! that! although!public! expenditure!was! low! in! both! absolute! terms! and! relative! to! the! country’s!GDP,! it!accounted!for!a!significant!proportion!of! total!government!expenditure—around!18.5%.1582,1583!This!proportion!represents!an!increase!from!1995!and!2000,!when!education!expenditure!accounted!for!only!9.36%!and!16.68%!of!the!total!state!budget,!respectively.1584!Low!aggregate!levels!of!state!revenue!and! the! overwhelming! needs! of! the! education! sector! may,! therefore,! support! the! Government’s!assertion! that! there! was! no! viable! alternative! to! private! sector`dominated! education! prior! to! the!earthquake,!as!any!expansion!of!public! sector!provision!would!have! required!a! significant! injection!of!funding!that!the!state!was!unable!to!provide.!!The! January! 2010! earthquake!had! a! devastating! impact! on! the!Haitian! education! system,! in! terms!of!both!human!and! infrastructure!costs.!Estimates!of!damages!differ!by!source.!According!to!MINUSTAH,!approximately!1,093,000! learners!were!affected;1585! the!Education!Cluster! estimated! that!1.26!million!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1582!L.!Wolff,!Education&in&Haiti:&The&way&forward,!Partnership!for!Educational!Revitalization!in!the!Americas!(PREAL)!(September!2008).!Available!at!http://www.thedialogue.org/PublicationFiles/Education%20in%20Haiti%20`%20The%20Way%20Forward%20`%20FINAL%20`%209`15`08.pdf!!


Education!30/2!(2000),!pp.!163`178.!1584!IMF,!Haiti:&Poverty&reduction&strategy&paper,!IMF!country!report!No.!09/290!(2009).!Available!at!http://www.imf.org/external/pubs/ft/scr/2009/cr09290.pdf!!


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children!and!700,000!schoolàge!children!were!directly!affected,1586!while!UNICEF!places!this!figure!far!higher,!at!2.5!million.1587!Of!those!affected,!the!Education!Cluster!estimates!that!around!38,000!students!were! killed1588,1589,1590! and! that! 250,000! schoolàge! children! became! IDPs! and! moved! to! indirectly!affected! Departments.1591! In! addition,! approximately! 55,793! teachers! and! education! personnel! were!affected!by!the!earthquake,!with!1,527!perishing!in!Ouest!Department!alone.1592,1593,1594,1595!This!loss!of!staff! has! provided! a! notable! barrier! to! the! reestablishment! of! education! services! during! the!reconstruction! process.! In! interpreting! these! statistics,! it! might! be! noted! that! the! disparity! of!organizations’! estimates!may! be! the! result! of! non`standardized! definitions! of! “affected,”! rather! than!measurement!inaccuracy.!!The!concentration!of!education!infrastructure!in!and!around!the!Portàu`Prince!metropolitan!area!also!contributed! to! the! catastrophic! impact! of! the! earthquake! on! physical! school! spaces.! UNICEF! studies!show!that!4,992!schools,!or!23%!of!all!schools! in!Haiti,!were!affected!by!the!earthquake.1596,1597,1598,1599!This! figure! represents! between! 80`90%! of! all! schools! in! the! earthquakeàffected! areas.1600,1601! Of! all!schools! in! the! affected! area,! 57%! have! been! classified! as! damaged,! while! 28%! were! completely!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1586!Haiti!Education!Cluster,!Education&cluster&bulletin:&18&February&2010!(February!2010).!Available!at!http://oneresponse.info/Disasters/Haiti/Education/Documents/ECU!English.docx!!


1588!Haiti!Education!Cluster,!Education&cluster&rapid&joint&needs&assessment&(RJNA):&RJNA&final&report!(March!2010).!Available!at!http://oneresponse.info/Disasters/Haiti/Education/Documents/RJNA%20Report%20ENGLISH.docx!!











1599!UNICEF,!UNICEF&rebuilds&education&in&Haiti&from&the&ruins!(January!2011).!Available!at!http://www.unicef.org/malaysia/media_news11ùnicef`rebuildsèducationìn`haiti`from`the`ruins.html!!



!


destroyed! (Figure! 106! and! Figure! 107).1602,1603,1604! In! addition! to! schools,! the! building! housing! the!Ministry!of!Education!was!also!significantly!damaged,!further!complicating!efforts!to!resume!education!activities.1605! Of! the! estimated! US$396.6! million! total! building! damage! sustained! by! the! education!system,!the!private!sector!incurred!US$363!million,!reflecting!the!dominance!of!these!enterprises!within!the!Haitian!education!system.1606!!Figure.106:.Damage.sustained.by.schools,.PortTauTPrince,.Leogane,.and.Jacmel.(chart),.March.2010.

!Source:!Haiti!Education!Cluster,!Education&cluster&rapid&joint&needs&assessment&(RJNA):&RJNA&final&report!(March!2010).!Available!at!http://oneresponse.info/Disasters/Haiti/Education/Documents/RJNA%20Report%20ENGLISH.docx!!

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Figure.107:.Damage.sustained.by.schools,.PortTauTPrince,.Leogane,.and.Jacmel.(table),.March.2010.

.. ..%.

Destroyed.%..

Damaged.%..

Appears.intact.

District. !! !! !! !!!! Port&au&Prince& 17! 70! 10!!! Leogane& 67! 29! 4!!! Jacmel& 7! 81! 11!

!! . . . .Source:!Haiti!Education!Cluster,!Education&cluster&rapid&joint&needs&assessment&(RJNA):&RJNA&final&report!(March!2010).!Available!at!http://oneresponse.info/Disasters/Haiti/Education/Documents/RJNA%20Report%20ENGLISH.docx!!

!!Immediately!following!the!January!2010!earthquake,!the!Haitian!government!ordered!schools!across!the!country!to!close.!On!1!February,!schools!in!indirectly!affected!Departments!were!authorized!to!reòpen,!and! 1,000! schools! in! SudÈst! Department! reòpened! at! the! beginning! of! March.! Within! Ouest!Department,!including!in!the!Portàu`Prince!metropolitan!area,!classes!were!permitted!to!resume!on!5!April,!with!the!focus!of!all!schools!shifting!to!non`formal!learning!and!providing!avenues!for!psychosocial!support.! UNICEF! reported! that! many! students! were! returning! to! classes! one! week! after! school! reòpening! in! Ouest! Department.1607! According! to! MINUSTAH,! by! July! 2010,! the! efforts! of! local!communities! and! Education! Cluster! partners! had! led! to! the! reopening! of! 80%! of! schools! in! Portàu`Prince,!72%! in! Leogane,! and!100%!of! schools! in!Petit! et!Grand!Goave!and! Jacmel,!most! in! temporary!structures.1608!By!December!2010,!the!Education!Cluster!stated!that!most!structurally!sound!schools!had!reopened.1609!!The! challenge!of! debris! removal!was! the!primary!obstacle! to! the! resumption!of! school! activities.! Site!identification! and! clearance! authorization! were! often! delayed! and! clearance! services! were!overwhelmed!by!demand.! Lack!of! rubble! removal!hampered! the!establishment!of! temporary! learning!spaces,! such! that!many! schools!were!unable! to! reòpen!even!when!permitted! to!do! so.1610,1611,1612! Six!months!after!the!earthquake,!approximately!40%!of!affected!school!sites!had!been!cleared!of!debris!by!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1607!UNICEF,!Children&of&Haiti:&Progress,&gaps&and&plans&in&humanitarian&action!(April!2010).!Available!at!http://www.unicef.org/romania/FINAL_UNICEF_Haiti_90`Day_Report_13_April_2010_FINAL.pdf!!


1609!Haiti!Education!Cluster,!Education&cluster&situation&report:&14&December&2010!(December!2010).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/reports/Education_Cluster_SitRep_14_12_2010.pdf!




!


local!communities!in!earthquakeàffected!areas,!while!a!further!200!(4%)!had!been!cleared!by!Education!Cluster! partners.1613! By!March! 2011,! Education! Cluster! partners! had! cleared! debris! from! 274! schools!(5.5%).1614!!Relief!efforts!to!stimulate!education!sector!recovery!focused!on!the!distribution!of!temporary!learning!spaces!and!tents!to!school!sites,1615! in!accordance!with!the!priorities!of!residents!expressed!during!the!Rapid! Joint! Needs! Assessment! in! March! 2010.1616! After! six! months,! 1,297! school! tents! had! been!distributed!by!UNICEF!and!its!partners,!resulting!in!the!establishment!of!225!temporary!learning!spaces,!while!the!Education!Cluster!had!provided!an!additional!367!school!tents.1617!Distributed!learning!spaces!were! estimated! to! support! 200,000! affected! learners.1618,1619! Eight!months! later,! by!March! 2011,! the!Education! Cluster! stated! that! 325,000! children! were! benefiting! from! temporary! learning! spaces!distributed!during!the!relief!effort.1620!!In!2011,!provision!of!learning!spaces!transitioned!from!the!distribution!of!tents!to!the!construction!and!rehabilitation! of! semi`permanent! and! permanent! structures,! with! the! Education! Cluster! reporting!significant!progress.!By!March!2011,!511!semi`permanent!and!170!permanent! schools! (681! total)!had!either!been! completed!or!planned! for! construction!or! rehabilitation!across!earthquakeàffected!areas!(Figure! 108).!UNICEF!highlighted! completion!of! 104! schools! in! Portàu`Prince,! accommodating! 26,500!students,!out!of!a! total! target!of!200!schools! in!earthquakeàffected!areas.1621,1622! In!September!2011,!the! Education! Cluster! stated! that! the! number! of! semi`permanent! and! permanent! school!


1614!Global!Education!Cluster,!Global&education&cluster&update:&January&5&March&2011,!Global!Education!Cluster!(2011).!Available!at!http://oneresponse.info/GlobalClusters/Education/publicdocuments/Education%20Cluster%20Update_January_March_2011_FINAL.pdf!



1617!UNICEF.!Children!of!Haiti:!Milestones!and!looking!forward!at!six!months.!2010.!1618!UN!MINUSTAH,!Haiti:&6&months&after…!(July!2010).!Available!at!http://www.un.org/en/peacekeeping/missions/minustah/documents/6_months_after_commemoration.pdf!!


1620!Global!Education!Cluster,!Global&education&cluster&update:&January&5&March&2011,!Global!Education!Cluster!(2011).!Available!at!http://oneresponse.info/GlobalClusters/Education/publicdocuments/Education%20Cluster%20Update_January_March_2011_FINAL.pdf!!

1621!Haiti!Education!Cluster,!Education&cluster:&Inputs&for&OCHA&humanitarian&bulletin!(March!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/reports/Education_Cluster_SitRep_Inputs_09032011.pdf!

1622!Haiti!Education!Cluster,!Education&cluster:&Inputs&for&OCHA&humanitarian&bulletin!(March!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/reports/Education_Cluster_SitRep_Inputs_09032011.pdf!!

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construction/reconstruction! projects! had! increased! to! 712! learning! spaces,1623! although! it! is! unclear!what!percentage!of!these!projects!had!been!completed.!The!Cluster!noted!in!August!2011!that!several!hundred!planned!schools!remained!in!need!of!construction!or!rehabilitation,1624!while!the!deterioration!of!tents!hosting!an!estimated!700!schools!necessitated!continued!commitment!to!school!reconstruction!by!Cluster!partners.1625,1626!!Figure.108:.Planned,.in.construction,.and.completed.semiTpermanent.and.permanent.school.reconstruction/rehabilitation,.by.commune,.March.2011.

!Source:!Haiti!Education!Cluster,!Education&cluster:&Inputs&for&OCHA&humanitarian&bulletin!(March!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/reports/Education_Cluster_SitRep_Inputs_09032011.pdf!!

!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1623!Haiti!Education!Cluster,!Education&cluster&information&bulletin:&24&September&2011!(September!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/news/Edu_Cluster_info_bulletin_23_sept_eng.pdf!

1624!Haiti!Education!Cluster,!Education&cluster&bulletin:&8&August&2011!(August!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/reports/Aout%202011/Education_Cluster_SitRep_080811.pdf!

1625!Haiti!Education!Cluster,!Education&cluster&situation&report:&11&July&2011!(July!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/reports/juillet%202011/Education_Cluster_SitRep_11072011.pdf!

1626!Haiti!Education!Cluster,!Education&cluster&bulletin:&8&August&2011!(August!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/reports/Aout%202011/Education_Cluster_SitRep_080811.pdf!!

3 The Education Cluster is a joint forum for all partners working in Education in Emergencies. Please send your progress, results, stories, photos and comments!

Contact : [email protected]

The Education Cluster is collecting the information on DRR activities, including

modules and the list of schools that your organization is working in to increase

coordination and to avoid duplication. Please update information on your DRR work

through the Activity Tracking Matrix (ATM) with the name of the schools where these

activities take place.

Schools that continue to operate under tents and which need demolition will require

special attention during the hurricane season due to their added vulnerability under

adverse weather. We have posted an updated list of schools which need the reinforcement of tents, demolition and construction on our website. If you

know of additional schools in this situation, please contact

[email protected] to share the information.

School Reconstruction Update.

Updated from last week’s report (by e-mail), a total of 504 semi-permanent schools and

116 permanent schools are built, being built or planned to be built in the earthquake-

affected West, South-east and Nippes Departments since the earthquake till today.

Please update your school reconstruction project information through the ATM with the

name of schools, status, the number of students etc. If you know of other organizations

doing school construction who do not currently report their activities to the Cluster,

please let us know so that we can advocate for better coordination.

0

20

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120

1 2

38

16 20

54

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26

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22 13

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23

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Semi-permanent

Permanent

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The!Haitian!government!has!identified!the!overhaul!of!the!education!system!as!one!of!the!priorities!in!its! Post`Disaster! Action! Plan.! Objectives! include! the! implementation! of! an! information! management!system,! establishing! an! accreditation! scheme,! reevaluating! the! public`private! sector! partnership!framework,! and!mapping!educational! establishments! across!Haiti.! In! addition! to! short`term!measures!designed!to!assist!children!to!return!to!school!and!implement!effective!bureaucracy,!the!state!has!also!identified!the!fulfillment!of!children’s!constitutional!right!to!free!education!as!a!priority!to!be!achieved!by!2020,!in!addition!to!expanding!the!state’s!role!in!education!provision.1627!!!

C.&Education&engagement&!The!government’s! lack!of!control!over! the!majority!of! the!Haitian!education!sector!and!the! lack!of!an!appropriate! information! management! and! reporting! system! mean! that! estimates! of! young! Haitians’!educational! engagement! must! generally! be! derived! from! large! household! surveys.! This! practice! can!undermine! data! reliability,! particularly! when! surveys! do! not! report! enrollment! and! attendance! using!standardized! age! categories,! don’t! use! population! estimates! in! analysis,! or! skew! results! using! other!flawed!methodologies.!!These! shortcomings! are! abundant! in! the! literature,! with! different! surveys! reporting! significantly!different! levels! of! engagement.! However,! as! large! international! databases! (such! as! the! World! Bank!World! Development! indicator! database,! the! World! Bank/UNESCO! education! database,! and! the!statistical!annexes!of!the!annual!UNDP!Human!Development!Report)!do!not!present!estimates!of!Haiti’s!education!enrollment!derived!more!recently!than!2001,!large,!rigorous!population`based!surveys!remain!the!only!viable!source!of!enrollment!information.!!!In!2006,!the!nationally!representative!EMMUS!IV!survey!estimated!that!approximately!85`90%!of!young!people! aged! 10`17! were! receiving! schooling! (Figure! 109).1628! Notable! differences! are! observable!between! urban! and! rural! areas,! while! gender! differences! are! negligible! except! for! lower! enrolment!among!girls!aged!17!in!rural!areas.!The!level!of!school!enrolment!gender!parity!found!in!the!EMMUS!IV!survey! confirms! the! 2002! conclusion! of! the! World! Bank! that! Haitian! parents! do! not! exhibit! gender!preference!when!deciding!which!of!their!children!to!enroll!in!school.1629!!!





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Figure.109:.School.enrollment.among.10T17.year.olds,.by.age,.sex.and.urban/rural.status,.2006.



!!The!EMMUS! IV!survey! indicated! that! the!proportion!of!Haitian!youth!who!are!out!of! school! increases!with!age.!The!survey!found!that!13.1%!of!girls!and!14.6%!of!boys!aged!10`14!were!out!of!school!in!2006!(Figure!110).! In!contrast,!26.4%!of!girls!and!19.6%!of!boys!aged!15`19!were!out!of!school! in! the!same!period!(Figure!111and!Figure!112).!Disparities!were!observed!by!urban/rural!status!in!both!age!groups.!Among! those! aged!10`14,! 9.5%!and!15.7%!of! girls! in! urban! and! rural! areas,! respectively,!were!not! in!school,!while! 7.1%! and! 18.5%!of! boys,! respectively,! in! urban! and! rural! areas!were! not! in! school.! The!proportion!of!out`of`school!adolescents!is!greater!among!those!in!the!15`19!age!group,!where!22%!and!31%!of!urban!and!rural!girls!are!out!of!school,!and!13%!and!24%!of!urban!and!rural!boys!do!not!attend!school,! respectively.1630! However,! as! observed! in! Figure! 109! above,! enrollment! proportions! do! not!monotonically!decrease!with!each!year!of!age,!such!that!some!groups!of!older!children!display!higher!enrollment!proportions!than!their!younger!counterparts.1631!!





!


Figure.110:.School.enrollment.among.10T14.year.olds,.by.sex,.Department,.urban/rural.status,.and.school.level,.2006.



!!!Figure.111:.School.enrollment.among.15T19.year.olds,.by.sex,.urban/rural.status,.and.school.level,.2006.(chart).

! !

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! !Source:!Population!Council/UNFPA,!The&adolescent&experience&in5depth:&Using&data&to&identify&and&reach&the&most&


!!Figure.112:.School.enrollment.among.15T19.year.olds,.by.sex,.Department,.urban/rural.status,.and.school.level,.2006.(table).



!!

!


When! children! aged! 6`9! are! included! in! the! analysis,! the! proportion! of! Haiti’s! children! not! attending!school! is! considerably! less! than! the! proportions! found! for! adolescent! girls! and! boys! aged! 10`19,!indicating!that!younger!children!are!more!likely!than!their!older!counterparts!to!have!been!enrolled!in!school! in!2006.!For!all!children!aged!6`17,!16%!of!girls!and!16.8%!of!boys!were!not!enrolled! in!school!during!the!survey!year!(Figure!113).!Those!in!rural!areas!were!approximately!twice!as!likely!not!to!have!been! enrolled! as! their! urban! counterparts,!with! significant! differences! between!Departments.1632! The!finding! that! approximately! 82%! of! children! in! the! 6`17! age! group! in! the! Portàu`Prince!metropolitan!area!were! attending! school! sharply! contrasts! the! 2006! finding! from!Kolbe! and!Hudson! that! 53.5%!of!children!aged!5`17! in!Portàu`Prince!were!not! in!school.1633!One!possible!source!of!discrepancy! is! that!Kolbe!and!Hudson!were!assessing!the!insecurity!following!of!the!departure!of!President!Aristide,!which!may!have! led!to!a!temporary!fall! in!enrollment,!as!well!as!their! focus!on!marginalized!neighborhoods.!Whatever!the!explanation,!Haiti’s!2008!Poverty!Reduction!Strategy!Paper!Country!Report!suggests!that!nonènrollment!for!the!5`15!age!group!stands!between!these!two!estimates,!at!40%,!or!approximately!one! million! children,! though! differences! in! assessed! age! group! and,! possibly,! geographical! coverage!should!be!highlighted.1634!!!





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Figure.113:.NonTenrollment.among.children.age.6T17,.by.sex.and.Department,.2006.



!!Most!estimates!of!school!enrollment!concern!the!age!group!5/6`11/12.!In!many!cases,!it!is!unclear!why!different!authors!chose!one!of!either!two!ages!for!each!endpoint!of!this!age!group.!In!fact,!it!is!entirely!possible! that!each!of! these!surveys! is!actually!describing! the!same!population,!depending!on!whether!children!must! already! have! turned! 6! before! admission! to! primary! school,! or!whether! they! can! enter!school!if!they!turn!six!during!the!course!of!their!first!year.!As!previously!discussed,!the!first!and!second!cycles! of! primary! school! together! include! six! years! of! instruction.! If! students! enter! the! first! grade! of!primary!school!at!age!five,!then!they!would!enter!the!final!grade!of!the!second!cycle!at!age!11.!However,!if!they!are!only!legally!allowed!to!enter!the!first!year!of!primary!school!having!already!turned!six,!then!they!would!be!12!during!their!final!year!of!the!second!cycle.!Confusion!regarding!these!age!cutoffs!for!entry! into!the!first!cycle,! in!addition!to!the!timing!of!surveys! in!relation!to!the!school!year,!may!mean!that!estimates!by!different!surveyors!are!comparable!despite!appearing!to!have!different!age!endpoints.!Consequently,!this!section!of!the!Report!will!assume!that!these!age!categories!are!comparable!and!will!refer!to!children!in!either!age!group!as!“school`aged!children.”!Even!so,!these!notable!discrepancies!in!age!categories!deserve!further!investigation.!!

!


Available!surveys!for!this!age!group!reveal!significant!discrepancies!between!estimates!of!the!proportion!of! schoolàged! children!not! enrolled! in! school.! A! 2008! government! report! of! the!2005/06! EMMUS! IV!survey,! for! example,! suggests! that! 55%! of! schoolàged! children! were! not! enrolled,! while! the! IMF’s!Poverty!Reduction!Strategy!Paper!Country!Report!and!the!National!Education!for!All!Strategy!both!state!a!primary!net!enrollment!ratio!of!76%.1635,1636,1637,1638!Also!in!2008,!Henriette!Lunde!estimated!that!40%!of!schoolàged!Haitian!schoolàged!children!were!not!in!school.1639!Lunde!noted!a!significant!difference!in! enrollment! rates! between!urban! and! rural! areas,! finding! that! in! 2003! 28%!of! schoolàged! children!were!not!in!school!in!the!Portàu`Prince!metropolitan!area!and!25%!in!other!urban!areas,!in!contrast!to!46%!of!rural!schoolàged!children.1640!These!estimates!are!far!higher!than!that!provided!for!2007!by!the!PanÀmerican!Health!Organization,!which!stated!that!only!17%!of!schoolàged!children!did!not!attend!school!and!that!this!proportion!was!greater!among!those!aged!under!ten.1641!!The!significant!variability!of!age`specific!enrollment!between!sources!makes!it!impossible!to!determine!conclusively! whether! school! enrollment! has! increased,! decreased,! or! remained! steady! over! the! past!decade.!Some!earlier!studies,!however,!suggest!very!little!change!over!the!past!ten!years.!For!example,!in!2000,! Salmi! found! that!37%!of! schoolàged! children!were!not!enrolled.1642! Similarly,! the!2001!Haiti!Living!Conditions!Survey!estimated!nonènrollment!within!the!range!of!more!recent!estimates,! finding!that! 23%! of! schoolàged! children! were! not! enrolled! (Figure! 114).1643! In! the! continued! absence! of!sufficient! administrative! data,! further! rigorous! population`based! surveys! are! required! both! to! update!outdated!estimates!of!school!enrollment!by!age!group,!and!to!provide!additional!reliable!estimates!of!enrollment!rates!across!Haiti.!!









Education!30/2!(2000),!pp.!163`178.!1643!D.!Verner,!Making&poor&Haitians&count:&Poverty&in&rural&and&urban&Haiti&based&on&the&first&household&survey&for&


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Figure.114:.School.attendance,.by.age.and.metropolitan/urban/rural.status,.2001.



!!The!impact!of!the!January!2010!earthquake!on!educational!engagement!must!be!considered!against!this!background.! Several! sources! have! stated! that! approximately! 500,000! schoolàged! children! were! not!enrolled! in! school! before! the! earthquake,! although! how! these! estimates! were! derived! remains!elusive.1644,1645,1646,1647,1648! Certainly! some! of! these! sources! are! outdated! or! otherwise! unreliable! as! a!means!to!determine!a!baseline!enrollment!on!the!eve!of!the!earthquake.!Yet!another!discrepancy!is!the!Education!Cluster’s!statement!that!400,000!schoolàged!children!were!out!of!school!on!the!eve!of!the!earthquake,! which! also! noted! that! extrapolated! UNICEF! estimates! indicate! that! 985,000! children! in!earthquakeàffected!areas,!and!2,506,805!children!across!Haiti,!lacked!access!to!primary!school.1649!This!discrepancy!may! be! the! result! of! numerous! factors,! including! the!misattribution! of! those! in! need! of!access! (all!children!under!age!ten!versus!those!aged!six`to`ten),!different!data!sources! for!age`specific!population!estimates!and!the!number!of!children!in!school,!and!the!conflation!of!children!in!earthquakeàffected!areas!with!those!in!other!areas.!!Nationally! representative! data! on! the! proportion! of! Haitian! children! attending! school! following! the!earthquake!did!not!exist!at! the! time!of!writing,!but!data!collected!as!part!of! the! IDP!Site!Registration!system!indicate!that!children!living!in!IDP!camps!may!have!greater!education!utilization!than!a!number!of! preèarthquake! estimates.! Across! the! 189! camps! registered! during! Phase! 2! of! the! registration!process,! the!UN!OCHA! found! that! 77%! children! aged!6`14!were! attending! school! (77.1%!of! boys! and!76.9%!of!girls),!with!greater!enrollment!among!those!aged!6`11!(78.2%)!(the!official!ages!for!grades!1`6)!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1644!U.S.!Department!of!Labor,!Haiti,!Bureau!of!International!Labor!Affairs!(2011).!Available!at!http://www.dol.gov/ilab/media/reports/iclp/Advancing1/html/haiti.htm!!






!


than! for! those! aged! 12`14! (74.7%)! (Figure! 115).! Encouragingly,! the! proportion! of! children! with!disabilities!enrolled!in!school!was!approximately!equal!to!the!average,!with!rates!of!76.1%,!76.6%,!and!75.5%,!respectively.!However,!only!21.5%!of!registered!internally!displaced!children!had!never!attended!school,!indicating!that!those!who!had!attended!school!prior!to!the!2010!earthquake!were!far!more!likely!to!be! in!school!after!the!earthquake!than!those!who!had!never!previously!been!enrolled.1650!As!noted!earlier,! significant! disparities! between! pre`earthquake! school! enrollment! estimates! do! not! permit!reliable!trend!analysis.!However,!the!Education!Cluster!has!stated!that!a!greater!proportion!of!children!who!are!now!internally!displaced!are!enrolled!in!school!than!before!the!earthquake.1651!!Figure.115:.School.enrollment.among.children.living.in.IDP.camps,.by.sex.and.age.group,.July.2011.

!Source:!Haiti!Education!Cluster,!Education&cluster&information&bulletin:&1&August&2011!(August!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/news/Edu_cluster_Info_Bulletin_29_juillet_2011_ENG.pdf!!

!!Over`age!students,!resulting!from!late!entry!and!low!promotion!and!high!repetition!rates,!represent!one!of!the!biggest!challenges!facing!the!Haitian!education!system.1652!This!problem!arises!as!early!as!the!first!grade!of! basic! education.!Although! little! recent! research!has!been! conducted!on! the!phenomenon!of!late!entrants,!the!lack!of!systemic!educational!reform!in!Haiti!means!that!analysis!conducted!in!the!late!1990s!into!the!dynamics!of!this!phenomenon!likely!remain!relevant.!In!the!school!year!1997/98,!437,132!children!entered!the!first!grade!of!basic!education.!Of!these!students,!343,488!were!over!the!official!age!of!admission.!As!such,!in!the!first!grade!of!primary!education,!an!astounding!78.58%!of!students!in!the!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1650!Haiti!Education!Cluster,!Education&cluster&bulletin:&8&August&2011!(August!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/reports/Aout%202011/Education_Cluster_SitRep_080811.pdf!!




1 The Education Cluster is a joint forum for all partners working in Education in Emergencies.

Please send your progress, results, stories, photos and comments!

Contact : [email protected]

Updates on the Education Cluster Activities 77 % of children of 6 – 14 years old in camps go to school

According to the IDP Sites Registration Phase 2 produced by IOM, 77% of

children of 6-14 years old in 189 camps

attend school (boys 77.1%, girls 76.9%).

For 6-11 years old (grade 1-6), the total

enrolment is 78.2%, while 74.7% for 12-

14 years old. Out of all children of age

6-18, 21.5% have never been to school.

The survey also reveals the enrolment

rate of children with disabilities: 76.1%

for children aged 6-14; 76.6% for boys and 75.5% for girls.

The majority of school-going children in camps attend schools outside the camps, in line

with the Ministry of Education’s policy not to establish schools within camps. According to the Education Cluster’s survey on camps conducted in November 2011 in collaboration with IOM, 9 out of 10 parents of out-of-school children state a lack of

financial resources as the reason of not sending their children to school. However, the

biggest dilemma is that few partners support school fees because of an unsustainable

nature of the intervention.

HAITI 2011

Information Bulletin– 01 August 2011

© UNICEF/Haiti/2011/Imoto

0%

10%

20%

30%

40%

50%

60%

70%

80%

6-14 6-11 12-14 15-18

77% 78% 75%

57%

77% 78%

74%

55%

77% 78% 75%

46%

Boys

Girls

Total

School enrolment in camps (IOM, July 2011)

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entering! cohort!were! already!over`aged,!while!only! 21.32%!were!of! the! correct! age! for! that! level.1653!Most!troublingly,!approximately!20%!of!all!students!in!the!first!two!grades!of!basic!education!were!aged!15!or!older—eight!years!behind!the!official!level!for!their!age.1654!!!Late!entry!was!not!uniform!across!Haiti,!with! significant!differences!existing!between!urban!and! rural!areas,!and!a!smaller!difference!between!boys!and!girls!at!the!aggregate!level!(Figure!116).!Urban!boys!were! 27%! more! likely! to! be! the! correct! age! for! entry! into! primary! school! (33%)! than! their! female!counterparts!(26%),!while!rural!boys!and!girls!were!equally!likely!to!be!over`aged!(83%).!In!comparison,!urban!girls!were!53%!more! likely! to!be! the!correct!age! for!entry! into!primary! school! (26%)! than! rural!girls!(17%),!while!urban!boys!were!almost!twice!as!likely!to!be!the!correct!age!of!entry!(33%)!than!rural!boys!(17%).1655!Of!rural!children,!the!most!unlikely!to!attend!school!at!the!correct!age!were!those!whose!head!of!household!had!little!or!no!education,!perpetuating!the!cycle!of!low!educational!attainment.1656!!Figure.116:.Percentage.of.children.entering.grade.1.at.the.required.age,.by.sex.and.urban/rural.status,.1997.

!Source:&B.!Hadjadj,!Education&for&all&in&Haiti&over&the&last&20&years:&Assessment&and&perspectives,!UNESCO!Education!for!all!in!the!caribbean:!Assessment!2000!monograph!series!No.!18!(2000).!Available!at!http://unesdoc.unesco.org/images/0013/001363/136393e.pdf!

!!Since! 1997,! the! proportion! of! students! who! are! late! entrants! has! reportedly! fallen! from! 79%! to!approximately! 50%.1657! However,! it! is! not! clear!whether! discrepancies! between! urban! and! rural! boys!and!girls!have!diminished,!remained!constant,!or!increased.!!The!Gross!Enrollment!Ratio!provides!another!method!to!examine!the!efficiency!of!the!Haitian!education!system.!As! noted!previously,! a!GER! above! 100%! indicates! that! there! are!more! students! enrolled! in! a!







!


level! of! education! than! there! are! children! of! the! age! normally! designated! for! that! grade.&Only! one!identified! source! estimates! Haiti’s! GER! for! the! past! decade,! the! Ministry! of! National! Education! and!Vocational! Training! (MENFP),! which! in! 2007! estimated! Haiti’s! GER! for! basic! education! (1st! and! 2nd!cycles! of! primary! education)! at! 136%.! This! figure! indicates! that!many! students!who!were! not! of! the!official!age! for! these!grades!were!enrolled! in! those!years.! In!stark!contrast,! the!MENFP!estimated!the!combined!GER!of!Haiti’s!3rd!primary!cycle!and!secondary!education!to!be!46.2%,!indicating!that!fewer!than!half!of!young!people,!of!any!age!were!enrolled!in!these!levels.1658&&

!Haiti’s& basic& education& GER& of& 136%! reflects! an! inefficient! system! whereby! late! entrants! and! those!repeating!grades!occupy!limited!school!places,!further!stressing!the!system.1659!Hadjadj!has!noted!that!this!ratio!grew!rapidly!between!1980!and!1990,!rising!from!76%!at!the!beginning!of!the!period!to!123.7%!near!the!end!of!the!millennium,!at!an!average!rate!of!growth!of!7.6%.1660&As!Figure!117!shows,!growth!in!enrollment!was! fueled!by! the!private! sector,!with!enrollment! in!public! schools! in!1990!approximately!the!same!as!ten!years!earlier.1661&In!fact,!92%!of!the!increase!in!enrollment!is!attributable!to!the!private!sector,!which!increased!its!proportion!of!enrollment!from!57%!in!1980/81!to!76%!in!1996/97.!Although!the!GER!continued!to!rise!during!the!following!decade,!it!did!so!at!a!slower!rate.!However,!as!discussed!previously,!the!share!of!enrollment!attributable!to!the!private!sector!continued!to!grow!to!80%!on!the!eve!of!the!January!2010!earthquake.1662,1663,1664,1665,1666,1667,1668!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1658!Cited!in!L.!Wolff,!Education&in&Haiti:&The&way&forward,!Partnership!for!Educational!Revitalization!in!the!Americas!(PREAL)!(September!2008).!Available!at!http://www.thedialogue.org/PublicationFiles/Education%20in%20Haiti%20`%20The%20Way%20Forward%20`%20FINAL%20`%209`15`08.pdf!!












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Figure.117:.Trends.in.the.evolution.of.basic.education.enrollment,.by.sector,.1980T1997.

!Source:!B.!Hadjadj,!Education&for&all&in&Haiti&over&the&last&20&years:&Assessment&and&perspectives,!UNESCO!Education!for!all!in!the!caribbean:!Assessment!2000!monograph!series!No.!18!(2000).!Available!at!http://unesdoc.unesco.org/images/0013/001363/136393e.pdf!

!!Because!so!many!students!are!over`age!for!their!grade,!gross!estimates!of!the!percentage!of!children!in!school! do! not! reflect! the! extent! of! the! education! deficit! in! Haiti.! This! is! also! why! accurate! analysis!requires! using! the! Net! Enrollment! Ratio! (NER)—! the! proportion! of! students! enrolled! in! a! level! of!education!who!are!of!the!age!normally!designated!for!that!grade—in!addition!to!the!GER.!Slightly!more!data! exist! on! Haiti’s! NER! than! its! GER,! possibly! because! the! primary!NER! is!measured! as! part! of! the!Millennium! Development! Project.! Nonetheless,! estimates! of! Haiti’s! NERs! again! vary! by! source! and!significantly! by! time! period.! According! to! Hadjadj,! Haiti’s! basic! education! (1st! and! 2nd! cycles! of! basic!education)!NER!was!67%! in!2000,!having! increased! from!38%! in!1980/81!and! from!64.6%! in!1996/97.!However,! this! level! of! correct`age! enrollment! was! not! uniform! across! Haiti,! with! some! Departments!significantly!outperforming!others!(Figure!118).1669!!!


!


Figure.118:.Basic.education.Net.Enrollment.Rates.(NERs),.by.Department,.2000.

!Source:!B.!Hadjadj,!Education&for&all&in&Haiti&over&the&last&20&years:&Assessment&and&perspectives,!UNESCO!Education!for!all!in!the!caribbean:!Assessment!2000!monograph!series!No.!18!(2000).!Available!at!http://unesdoc.unesco.org/images/0013/001363/136393e.pdf!!

!!Additionally,!Haiti’s!Net!Intake!Rate!(new!entrants!in!the!first!grade!of!primary!education!who!are!of!the!official!primary!school!entrance!age,!expressed!as!a!percentage!of!the!population!of!the!same!age1670)!was!found!to!be! lower!than!the!total!basic!education!NER,!at!only!47.5%.!The!difference!between!the!net!intake!rate!and!Haiti’s!basic!education!NER!supports!Hadjadj’s!conclusion!that!“children!enroll!in!the!first!and!second!cycles!of!formal!basic!education!at!higher!ages.”1671!!Other!sources!provide!significantly!different!estimates!for!more!recent!time!periods.!The!International!Monetary! Fund! (IMF)! and! Haitian! Government! declared! that! Haiti’s! 2006! basic! education! NER! was!49.6%,! indicating! a! decrease! since! 2000! from! 54.3%.1672! The! Pan`American! Health! Organization!estimated!in!2007!that!Haiti’s!basic!education!NER!was!60%,!with!urban!children!3.5!times!more!likely!to!be!attending!school! in!the!correct!grade!for!their!age!than!their!rural!counterparts.1673!In!contrast,!the!Ministry!of!National!Education!and!Vocational!Training!(MENFP)!estimated!Haiti’s!2007!basic!education!NER!to!be!76%.1674!By!2008,!Haiti’s!Poverty!Reduction!Strategy!Paper!(PRSP)!and!National!Education!for!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1670!UNESCO,!Net&intake&rate!(2011).!Available!at!http://glossary.uis.unesco.org/glossary/en/home!!1671!B.!Hadjadj,!Education&for&all&in&Haiti&over&the&last&20&years:&Assessment&and&perspectives,!UNESCO!Education!for!all!in!the!caribbean:!Assessment!2000!monograph!series!No.!18!(2000).!Available!at!http://unesdoc.unesco.org/images/0013/001363/136393e.pdf!




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All! Strategy! had! also! adopted! this! estimate! of! 76%,! despite! the! results! of! the! EMMUS! IV! survey!completed!two!years!earlier!concluding!that!55%!of!schoolàged!children!were!not!in!school.1675!!!Estimates!of!Haiti’s!secondary!NER!(considered!by!the!international!community!to!be!Haiti’s!3rd!cycle!of!primary!education!and!secondary!education!combined)!are!far!lower!than!that!for!basic!education.!Even!when!using!2007!MENFP!estimates,!which!stated!the!highest!basic!education!NER!of!any!source,!Haiti’s!secondary!NER!was!estimated!to!be!only!22%.1676!This!indicated!that!roughly!one!of!five!Haitian!children!of!“secondary”!age!is!attending!the!correct!education!level!for!his!or!her!age.!!Comparing!the!NER!and!GER!provides!an! indication!of! the! level!of! internal!efficiency!of! the!education!system—without!prejudice!to!the!acceptability!of!access!to!education!or!dropòut!rates,!parity!between!the! NER! and! GER! indicates! internal! efficiency,! in! that! no! students! are! repeating! grades! or! entering!school!late.!Such!comparisons!in!Haiti!show!that!the!education!system!is!characterized!by!very!low!levels!of!internal!efficiency.!According!to!the!MENFP,!in!2007,!Haiti’s!basic!education!GER!(136%)!was!1.8!times!greater!than!its!corresponding!NER!(76%).!For!“secondary”!education!this!disparity!is!even!greater,!with!the! MENFP! estimating! that! Haiti’s! 2007! secondary! GER! (46%)! was! 2.1! times! greater! than! the!corresponding!NER!(22%).1677!The!contrast!between!Haiti’s!GER!and!NER!at!both!the!basic!and!secondary!level!highlights!the!degree!of!grade!repetition!and!late!entry!in!the!education!system,!resulting!in!a!large!number!of!overàge!students,!and!leading!to!poor!outcomes!for!students,!their!families,!and!the!system!itself.!!As! will! be! discussed! in! more! depth! below! (see! Section! 8E.& Access& to& education& and& barriers& to&enrollment),! two! primary! factors! stand! out! as! impediments! to! the! ability! of! children! to! enter! basic!education!at!the!correct!age:!limited!availability!of!school!spaces,!and!cost.!Limited!school!space!is!the!driving!cause!of!late!entry,!as!schools!may!give!preference!to!students!who!have!completed!parts!of!the!first!grade!but!were!forced!to!repeat!due!to!poor!performance.!However,!the!major!cause!of!the!lack!of!availability!of!school!spaces!can!be!conceived!of!as!a!“backlog”!of!students!who!have!wished!to!enter!basic!education!for!years,!but!have!been!prevented!due!to!previous!unavailability!of!spaces.!This!finding!led!the!Ministry!of!Education,!Youth!and!Sports!to!state!in!a!2000!Education!for!All!report!that!“one!may!be!tempted!to!say!that!if!the!problem!of!overàge!students!did!not!exist,!the!system!could!at!that!point!




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have! absorbed! all! children! aged! six! years,! and! still! have! had! a! good! number! of! places! left! over.”1678!Secondly,! many! parents! delay! their! child’s! entry! into! basic! education! because! of! acute! or! chronic!socioeconomic!issues,!and!may!need!to!save!more!money!for!their!child’s!education.!!Catalyzed!by!late!entry!students,!the!Haitian!education!system!is!saddled!by!very!high!rates!of!repetition!in!subsequent!grades.!These!high!repetition!rates,!in!association!with!late!entry!and!dropòuts,!create!an!inefficient!system.!One!study!conducted!by!the!Research!Triangle!Institute!in!1995!found!that!only!13%!of! Haitian! students! would! complete! the! first! and! second! cycles! of! basic! education! without! having!repeated!a!grade.!In!1997,!Hadjadj!estimated!the!repetition!rate!to!be!20%!per!year.1679!In!2000,!Salmi!estimated!the!rate!to!be!lower,!at!approximately!12%!per!grade.1680!In!2008,!Wolff!noted!that!the!official!primary!school! repetition!rate!was!13%,!however,!his!own!research! led!him!to!conclude!that! the!true!rate! was! probably! double! that! figure.1681! Cumulatively,! these! high! rates! of! repetition! significantly!undermine! the! internal!efficiency!of! the!school! system.!Using!data! from!the!1997/98!school!year,! the!Haitian!Ministry!of!Education,!Youth!and!Sports!estimated!high!rates!of!repetition!and!very!high!dropòut! rates! that! produce! a! system! in!which! it! takes! 16! rather! than! six! years! of! effort! and! resources! to!produce!one!basic!education!graduate.1682!!!The!cumulative!impact!of!grade!repetition!can!be!observed!in!Figure!119!from!the!1996/97!school!year.!While! a! very! significant! proportion! of! students! are! overàge! in! their! first! year! of! basic! education!(78.58%),! this! proportion! continues! to! monotonically! increase! with! grade! level,! such! that! nearly! all!students! (94.49%)! in! 6th! grade!were!overàge! in! 1996/97.1683! This!monotonic! increase!occurs! because!students!held!back! in! their! first! year!will! be!overàge! for! the! rest!of! their! school! lives,! and!additional!repeaters!will!be!added!in!successive!grades,!while!other!overàge!students!do!not!drop!out!of!school!at!a! counter`balancing! rate.! Although! late! entry! drives! the! high! prevalence! of! overàge! students,! low!





Education!30/2!(2000),!pp.!163`178.!1681!L.!Wolff,!Education&in&Haiti:&The&way&forward,!Partnership!for!Educational!Revitalization!in!the!Americas!(PREAL)!(September!2008).!Available!at!http://www.thedialogue.org/PublicationFiles/Education%20in%20Haiti%20`%20The%20Way%20Forward%20`%20FINAL%20`%209`15`08.pdf!!





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promotion! rates! between! the! first! and! second! years! (a! transition!which,! by! law,! is!meant! to! happen!automatically)!is!also!a!significant!shortcoming!of!the!education!system!driving!the!phenomenon.1684!!!Figure.119:.Number.and.percentage.of.overTaged.students.relative.to.total.enrollment,.by.grade,.1998.



!!At!the!aggregate!level,!the!proportion!of!students!who!were!over`age!for!the!basic!education!schedule!(aged! 12! or! over)! decreased! slightly! between! 1993/94! and! 1997/98,! from! 51.07%! to! 47.36%,!respectively! (Figure!120).1685!However,! a!number!of! sources!estimate! that! this!problem!has! increased!since! then,! with! estimates! of! overage! students! ranging! between! 50%! and! 72%! for! basic! education!students,!and!up!to!78%!for!secondary!students.1686,1687,1688,1689,1690!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1684!U.S.!Department!of!Labor,!Haiti,!Bureau!of!International!Labor!Affairs!(2011).!Available!at!http://www.dol.gov/ilab/media/reports/iclp/Advancing1/html/haiti.htm!!




1687!L.!Wolff,!Education&in&Haiti:&The&way&forward,!Partnership!for!Educational!Revitalization!in!the!Americas!(PREAL)!(September!2008).!Available!at!http://www.thedialogue.org/PublicationFiles/Education%20in%20Haiti%20`%20The%20Way%20Forward%20`%20FINAL%20`%209`15`08.pdf!!



Education!30/2!(2000),!pp.!163`178.!1690!U.S.!Department!of!Labor,!Haiti,!Bureau!of!International!Labor!Affairs!(2011).!Available!at!http://www.dol.gov/ilab/media/reports/iclp/Advancing1/html/haiti.htm!!

!


Figure.120:.Number.and.percent.of.overTage.students.in.basic.education,.1993T1998.



!!While!Figure!119!highlights!the!significant!proportion!of!students!who!are!one!or!more!years!older!than!the! official! age! for! their! grade! level! (or! the! “breadth”! of! the! problem),! it! fails! to! demonstrate! the!proportion! of! children!who! are! significantly! older! than! the! official! age! (the! “depth”! of! the! problem).!According! to! Hadjadj,! in! the! 1996/97! school! year,! 47.6%! (680,188! students)! of! all! basic! education!students!were! four!or!more! years!behind! for! their! age.!However,! this!was!a! reduction! from!53.2%! in!1980.1691!On!the!eve!of!the!January!2010!earthquake,!the!situation!was!even!more!dire!–!70%!of!basic!education!students!were!three!or!more!years!behind!their!official!grade!level,1692!while!Wolf!stated!that!three!quarters!of!primary!school!students!were!two!or!more!years!over`age!in!2008.1693!!The!Haitian!Government! has! noted! the!many! negative! effects! of! having! such!wide! ranges! of! student!ages! in! a! single! class,! especially!on! the!ability!of! teachers! to!manage! the! classroom.!Additionally,! the!Government! has! observed! that! the! financial! and! opportunity! costs,! and! psychosocial! impact,! of!repeating!successive!grades!forces!many!children!to!drop!out!of!school,!either!because!their!family!can!no!longer!support!their!enrollment,!or!because!they!have!become!discouraged!by!the!formal!education!system.1694!!






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The!Haitian!Government!noted!in!2000!that!between!1994!and!1998,!the!number!of!overàged!students!in! public! schools! had! fallen! by! 24%! (from!224,812! to! 170,846! students),!while! the! number! in! private!schools!had!increased!by!60.48%!(from!331,999!to!532,804!students).!For!the!1997/98!school!year,!the!private! sector! accounted! for! 75.74%!of! all! overàged! students! (Figure! 121).!While! this! is! a! significant!majority,! the! distribution! of! students! between! public! and! private! schools! means! that! this! level! is!proportional! to! enrollment,! as! the! proportion! of! all! students! attending! private! schools! similarly!increased!over!this!period.!Unfortunately,!more!recent!estimates!are!unavailable.!!Figure.121:.Number.of.overTage.students.in.basic.education,.by.sex.and.sector,.1998.



!!In!1997/98,!there!was!approximate!gender!parity!for!the!probability!of!being!an!overàge!student,!with!slightly! more! boys! overàge! in! basic! education! (52.4%,! or! 368,449! students)! than! girls! (47.6%,! or!335,201!students).!This!gender!bias!in!favor!of!girls!was!true!in!both!the!public!and!private!sectors.1695!It!is!unclear!whether!this!characteristic!has!continued!since.!!Until!1996,!there!was!also!relative!parity!between!students!in!urban!and!rural!areas.!However,!in!1997!and! 1998,! the! proportion! of! overàge! students! in! urban! basic! education! fell! from! 51.31%! to! 40.76%,!while! in! rural! areas,! the! proportion! increased! from! 48.69%! to! 59.24%.! It! is! unclear!what! caused! this!disparity,! although! one! possibility! is! that! rural! students! were! more! likely! to! leave! their! studies!temporarily!during!the!rainy!season!to!help!their!families!with!agricultural!work,!reducing!their!ability!to!pass!their!endòf`year!exams.1696!This!possibility,!in!combination!with!the!proliferation!of!private!schools!over!the!period!that! illegally!required!students!to!pass!an!exam!to!progress!within!cycles,!may!explain!part!of!this!discrepancy,!as!absenteeism!due!to!agricultural!work!affects!rural!children!more!than!urban!children,!while!failing!endòf`year!exams!would!hold!such!students!back.!!In!addition!to!being!plagued!by!late!entry!and!overàge!students,!Haiti’s!education!system!is!also!marked!by! significant! rates! of! student! dropòuts.! In! 1996,! only! 55%! of! students! who! began! school! would!





!


complete!the!two!cycles!of!basic!education.!Other!countries! in!the!Caribbean!performed!far!better,!at!between!72`100%.1697!Figure!122!presents!a!cross`sectional!distribution!of!students!who!had!remained!in! school! in!1980/81!and!1996/97,! and! illustrates! that!dropòut! rates!were!higher! in!1996/97! than! in!1980/81.!Figure!123!shows!that!of!all!students!entering!the!first!year!of!basic!education!1996/97,!only!46.2%!were! still! enrolled! by! the! 6th! year.! Both! Figures! show! that! the! largest! dropòut! rate! occurred!between!the!first!and!second!year!of!basic!education,!at!almost!20%!of!all!those!who!enrolled.1698!It! is!worth!noting! that!a!perfectly!efficient! system!would!have!no!dropòuts,!and!all!grades!would! register!100%!in!Figure!123.!!Figure.122:.Distribution.of.students.(%),.by.grade,.1981.and.1997.


!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1697!V.!Jules!and!A.!Panneflek,!Subregional&synthesis&report:&Volume&I&5&Summary,!Education!for!all!in!the!Caribbean:!Assessment!2000!(2000).!Available!at!http://www.unesco.org/carneid/synthesis`1.pdf!


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Figure.123:.Student.survival.of.a.synthetic.cohort,.by.grade,.1997.


!!A! 1996! analysis! by! Hadjadj! highlights! the! cumulative! impact! of! grade`specific! drop`out! rates! in! basic!education!(Figure!124).!Out!of!a!synthetic!cohort!of!1,000!students!entering!the!first!grade,!192!(19.2%)!dropped! out! before! the! second! grade,! and! only! 452! (45.2%)! continued! to! the! last! year! of! basic!education.!Of!those!who!did!continue!to!the!sixth!grade,!a!further!21%!dropped!out!before!starting!the!third! cycle.1699! A! similar! study! by! the! Haitian!Government! a! year! prior,! in! 1995,! found! that! 43.4%! of!those! enrolling! in! grade! 1! went! on! to! complete! basic! education,! and! 28.8%! continued! to! the! third!cycle.1700! By! 2005,! the! Government! reported! that! only! 35%! of! children! completed! the! fifth! grade,!indicating! that! a! smaller! percentage!would! finish! the! suite!of! basic! education,! and!even! fewer!would!continue!on!to!the!third!cycle!than!in!1995.1701!!





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Figure.124:.Dropout.rate.in.basic.education,.by.grade,.1997.


!!By! 2007/2008,! most! sources! indicated! that! approximately! 60%! of! children! did! not! complete! basic!education,1702,1703,1704,1705!and!that!roughly!30%!drop!out!after!their!first!or!second!year.1706!This!finding!is!in!contrast! to! the!World!Bank’s!estimate! that!67%!of! students!entering!basic!education!will! complete!the! first! two! cycles,1707! but! is! roughly! consistent! with! Salmi’s! estimate! from! 2000! that! 10`15%! of!students,! on! average,! drop! out! between! each! grade.1708! In! contrast,! the! Poverty! Reduction! Strategy!Paper’s!claim!that!only!6%!of!students!drop!out!between!each!grade!is!inconsistent!with!their!estimate!of!the!primary!completion!rate!and!the!statement!that!29%!of!students!will!drop!out!between!the!first!and!second!grade.1709!!!








Education!30/2!(2000),!pp.!163`178.!1709!IMF,!Haiti:&Poverty&reduction&strategy&paper,!IMF!country!report!No.!08/115!(2008).!Available!at!http://www.imf.org/external/pubs/ft/scr/2008/cr08115.pdf!!

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According! to! the! Haitian! Government,! 46%! of!men! and! 39%! of! women! across! Haiti! have! completed!primary! education,! with! significant! differences! between! rural! and! urban! areas.1710! In! 2000,! Lunde!estimated! that! 64%! of! urban! youth! had! completed! primary! education,! while! only! 30%! of! their! rural!peers! had! achieved! the! same! level.1711! This! urban/rural! disparity! is! exacerbated!on! entry! to! the! third!cycle,! as! 40%!of! children! in! the! Port`au`Prince!metropolitan! area! continue! on! to! the! 7th! grade,!while!fewer!than!10%!of!rural!children!doing!the!same.1712!!!Driven! by! low! transition! rates! from! basic! education,! very! few! students! progress! to! secondary! and!tertiary! education! in! Haiti.! Only! 21`23%! of! children,! or! roughly! one! fifth,! will! be! educated! at! the!secondary! level,1713,1714,1715! and! only! 1.1%! will! continue! to! tertiary! studies.1716! Tertiary! enrollment!exhibits! a! gender! bias,! with! men! twice! as! likely! (1.4%)! to! continue! to! tertiary! studies! as! women!(0.7%).1717! Only! 0.6%! of! Haitian! workers! have! a! diploma! or! certificate! in! a! professional! or! technical!field.1718!Haiti!is!also!victim!to!a!significant!“brain!drain,”!with!an!estimated!eight!out!of!ten!Haitians!with!college!degrees!not!living!in!Haiti,!a!significant!obstacle!to!Haiti’s!future!development.1719!!Even! those! children! who! remain! enrolled! in! school! face! challenges! to! attendance.! Children! in! Haiti!generally!participate!in!the!domestic!and!agricultural!work!of!their!household.!As!such,!during!the!most!labor`intensive! periods,!many! students! leave! school! to! assist! their! families!with! the! harvest! or! other!household!duties.1720,1721!Lunde!notes!that!this!is!a!recurrent!problem!in!rural!areas!on!market!days,!as!













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students! will! miss! one! day! of! school! a! week! to! assist! their! family! transporting! and! selling! goods.1722!Physical! barriers! also! prevent!many! from! attending! school! at! some! times! during! the! year,! especially!after! the! hurricane! season! when! damaged! school! buildings! and! impassable! roads! prevent!attendance.1723!Due!to!these!barriers,!enrollment!rates!may!not!provide!the!complete!picture!of!Haitian!children’s! educational! engagement.! While! enrolled,! many! children! may! not! be! able! to! attend! their!classes,!thus!placing!them!at!a!disadvantage.!As!mentioned!earlier,!too,!many!schools!require!(illegally)!the!successful!completion!of!an!endòf`year!exam!for!progression!to!the!next! level,!nonàttendance!in!many! cases! forces! children! to! repeat! the! same! grade,! increasing! the! problems! of! overàge! students,!dropòuts,!and!systemic!inefficiency!–!not!to!mention!compromising!the!child’s!educational!attainment.!!!

i..Vulnerable.subTpopulations.!The! World! Bank! noted! in! 2006! that! “education! is! the! single! most! important! determinant! of! an!individual’s!potential!to!escape!poverty!in!Haiti.”1724!At!present,!education!is!unequally!distributed!across!the!population!in!Haiti,!especially!between!those!in!urban!and!rural!areas,!challenging!programmers!and!policymakers!to!design! interventions!that! increase!rural!access!to!education!(see!Section!8E.&Access&to&education&and&barriers& to&enrollment).!Verner!has!noted!that!unequal!distribution!of!education!access!can!be!more!easily! reduced! than! income! inequality,!but! that!education!access! reform!does!not!affect!income!inequality!significantly! in!the!short`term.1725!Education!access!reform!is,!therefore,!a! long`term!poverty!reduction!investment!yielding!benefits!as!successive!cohorts!pass!through!the!education!system!and!into!the!workforce.! The! significant! association! between! poverty! and! education! can! be! observed! in! Figure! 125,! which!illustrates!the!percentage!of!respondents!who!had!completed!educational!benchmarks!disaggregated!by!income!quintile,!derived!from!2001!Haiti!Living!Conditions!Survey!data.!While!the!majority!of! those! in!the!poorest! income!quintile!have!not! received!any!education!at!all,! almost!half! (49.6)!of! those! in! the!highest!quintile!have!completed!secondary!education!(44.6%)!or!higher!(5%).1726!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1721!H.!Lunde,!Youth&and&education&in&Haiti:&Disincentives,&vulnerabilities&and&constraints,!Fafo!paper!2008/26!(2008).!Available!at!http://www.fafo.no/pub/rapp/10070/10070.pdf!!








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Figure.125:.Highest.education.level.completed,.by.wealth.quintile,.2001.



!!As! educational! attainment! increases,! the! probability! of! falling! below! the! poverty! line! monotonically!decreases! in!metropolitan,!urban,!and!rural!areas!(Figure!126),!though!it! is!not!possible!to!extrapolate!that! this! observed! association! is! causal! (see! below).! While! poverty! is! more! widespread! in! non`metropolitan!urban!and!rural!areas!than!the!Port`au`Prince!metropolitan!area,!the!probability!of!falling!below!the!poverty! line!decreases!by!approximately!the!same!amount!(44`50%)!as!one!moves!from!no!completed!schooling!to!completing!secondary!school.1727! In!urban!and!rural!areas,! the!probability!of!a!household!head! falling!below!the!poverty! line! is! reduced!by!a!greater!percentage! for! those!who!have!moved! from!primary! completion! to! secondary! completion! (27%! and! 35%,! respectively)! than! from!no!education! to! primary! completion! (23%! and! 17%,! respectively).! The! transition! from! completing!secondary!to!tertiary!education,!in!turn,!also!reduces!the!probability!of!a!household!head!being!below!the!poverty!line!in!metropolitan,!urban,!and!rural!areas!alike!(81%,!66%!and!80%,!respectively).!!



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Figure.126:.Poverty.headcount.proportion,.by.education.level.and.urban/rural/metropolitan.status,.2001.



!!Less! clear! is! the! proportion! of! this! effect! attributable! to! the! attainment! of! education! itself,! and! the!proportion! inherent! in! an! individual’s! pre`existing! socioeconomic! standing.! The! question! of! reverse!causality!must! be! addressed,!whereby! children! in! richer! households! are!more! likely! to! stay! in! school!longer! (due! to! decreased! access! restrictions),! and! may! therefore! be! automatically! wealthier! after!completing! studies.! The! Pan`American! Health! Organization! noted! in! 2007! that! the! secondary! GER! of!children! from!affluent! households!was! far! higher! (71%)! than! that! of! children! from!households! in! the!lowest! income! quintile! (23%).1728! In! addition,! wealthier! household! heads! are! more! likely! to! have!completed!higher! levels!of!education!and!may!place!greater! importance!on!keeping!children! in!school!than! their! less! affluent! counterparts—factors! both! strongly! correlated! with! children’s! level! of!


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educational! attainment.1729! These! considerations! may! be! considered! to! be! “inter`generational”!determinants!of!education!and!poverty.!!Despite!these!inter`generational!determinants,!however,!strong!associations!remain!between!education!completed! and! work! sector! attained! upon! the! completion! of! studies.! Primary! education! completion!increases! the! probability! of! employment! in! high`return! industries! to! approximately! 21%.1730! The!probability! of! nonàgricultural! work! also! increases! in! both! urban! and! rural! areas! as! educational!attainment! increases.! This! association! between! level! of! completed! education! and! work! sector! are!significant!for!all!levels!of!education.1731!Though!probable,!it!is!not!possible!to!state!that!this!is!a!causal!relationship.!!In!addition! to!poverty!and! rural! location,!a!number!of!additional!characteristics!can!be! identified! that!make!certain! sub`groups!particularly! vulnerable! to!disengagement!with! the!Haitian!education! system.!Among!these!are!disabilities.!In!fact,!only!1.7%!of!disabled!schoolàged!children!were!enrolled!in!special!schools! in! 2002! due! to! a! lack! of! staff! and! the! disabled! children’s! low! priority! within! the!Ministry! of!Education.!The!few!centers!in!existence!were!privately!operated,!as!the!Government!has!invested!very!little! in!special!education.1732!However,!as!noted!previously,! information!from!the!postèarthquake!IDP!registration! process! revealed! comparable! estimates! of! school! enrollment! between! disabled! and! non`disabled! child! IDPs.! It!was! found! that! 77%!of! non`disabled! children! aged! 6`14!were! attending! school!(77.1%!of!boys!and!76.9%!of!girls),!with!greater!enrollment!among!those!aged!6`11!(78.2%)!(the!official!ages!for!grades!1`6)!than!for!those!aged!12`14!(74.7%).!Similarly,!the!proportion!of!internally!displaced!disabled!children!enrolled!in!school!was!approximately!equal!to!the!average,!with!rates!of!76.1%,!76.6%,!and!75.5%,!respectively.1733!!Another!high!risk!sub`group!includes!girls!who!become!married!or!pregnant!while!in!school.!These!girls!face! a! far! greater! risk! of! dropping! out! of! school! than!other! girls.1734,1735,1736! In! part,! this! is! due! to! the!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1729!M.!Justesen!and!D.!Verner,!Factors&impacting&youth&development&in&Haiti,!World!Bank!policy!research!working!paper!No.!4110!(2007).!Available!at!http://ddpèxt.worldbank.org/EdStats/HTIprwp07.pdf!!









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discriminatory!treatment!of!pregnant!students,!who!are!sanctioned!and!often!dismissed,!while!the!boys!responsible!for!their!pregnancies!are!largely!held!unaccountable.1737!Dismissal!from!school!also!removes!one!avenue!for!support!services!to!be!delivered!to!a!pregnant!adolescent,!marginalizing!her!further.1738!These!girls!also!face!greater!vulnerability!to!poverty,!as!the!household!dependency!ratio!increases!with!the!birth!of!each!additional!child.!In!contrast,!more!education!is!negatively!associated!with!fertility,!such!that!the!more!education!a!woman!attains,!the!fewer!children!she!is!likely!to!have!over!her!lifetime.1739!!Children!not!living!with!either!parent—either!because!they!have!been!orphaned,!because!they!are!living!with! their! spouse,!or!because! they! live!with!another! relative—are!also! less! likely! to!attend!school.1740!Children!not!living!with!either!parent!and!not!in!school!made!up!5%!of!the!total!female!population!and!3.9%! of! the! total! male! population! aged! 10`14! in! 2001,! with! differences! in! prevalence! between!Departments! and! urban/rural! status! (Figure! 127).1741! Without! family! support,! these! children! often!cannot!afford!to!go!to!school! (in!the!case!of!those! living!alone),!and!do!not!have!positive!role!models!encouraging!their!attendance.!As!highlighted!in!Section!5E.&Children&in&and&of&the&street,!the!fact!that!in!popular!parlance,!timoun&lari!(children!of!the!street)!are!generally!contrasted!to!timoun&lekol!(children!in!school),!rather!than!timoun&lakay!(children!in!homes),!suggests!the!link!between!living!on!the!street!and!school!disengagement!is!widely,!if!not!necessarily!consciously,!recognized.1742!!










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Figure.127:.Adolescents.not.in.school.and.not.living.with.either.parent,.by.sex,.Department,.and.urban/rural.status,.2006.



!!The!other!major!group!of!children!disenfranchised!by!the!current!educational!system!in!Haiti!is!children!in!domestic!servitude,!known!(pejoratively)!as!restaveks.!In!1999,!a!report!to!the!UN!General!Assembly!noted!with! distress! that! “77! per! cent! of! such! children! reach! 15,! 16,! or! 17! years! of! age!without! ever!having!attended!school.”1743!Roughly!55%!of!restavek!children!attended!evening!classes! in!1999,!while!7%!attended!a!vocational!school,!and!a!further!2%!attended!secondary!school.!Access!to!education!for!these!children!is!far!below!that!of!other!children!their!age.!This!topic!is!discussed!further!in!Section!9A.&Children&in&domestic&service&and&servitude.!!Unlike! many! developing! countries,! Haiti! has! exhibited! relative! gender! parity! in! education!engagement.1744,1745,1746! A!World! Bank! finding! that! parents! had! no! preference! between! sending! their!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1743!UN!GA,!Situation!of!human!rights!in!Haiti,!UN!Doc.!A/54/366!(1999).!Available!at!http://www.unhcr.org/refworld/docid/3b00f2431c.html!!


!


sons!or!daughters!to!school1747!was!again!confirmed!in!the!2008!Haiti!Youth!Survey.1748,1749!In!fact,!over!the!past! twenty!years,! the!gender! ratio! in!primary!education!has!shifted! in! favor!of!girls.! In!1990,! the!girl/boy!ratio!in!primary!education!was!0.94.!By!2000,!it!had!increased!to!1.08,!before!decreasing!again!to!1.02!by!2006.1750!In!secondary!education,!boys!maintain!a!slight!majority,!exhibiting!a!girl/boy!ratio!of!approximately! 0.94.! Smoothed! over! the! time! period,! Figure! 128! illustrates! Haiti’s! progress! towards!achieving!MDG!3.1:!equality!in!primary!and!secondary!education.1751!!Figure.128:.Girl/boy.ratio.in.primary.and.secondary.education,.1990T2005.


!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1745!B.!Hadjadj,!Education&for&all&in&Haiti&over&the&last&20&years:&Assessment&and&perspectives,!UNESCO!Education!for!all!in!the!caribbean:!Assessment!2000!monograph!series!No.!18!(2000).!Available!at!http://unesdoc.unesco.org/images/0013/001363/136393e.pdf!







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In!2002,!the!World!Bank!found!that!there!was!approximate!gender!parity!in!school!enrollment!for!the!6`10!age!group,!with!girls!outnumbering!boys!in!rural!areas,!while!boys!outnumbered!girls!in!urban!areas.!For!the!11`15!age!group,!the!enrollment!ratio!was!skewed!further!in!favor!of!girls,!with!significant!gains!in! urban! areas.! However,! boys! accounted! for! a! far! greater! proportion! of! students! in! the! 16`20! age!group.1752!This!finding!lends!support!to!UNICEF’s!assertion!that!“while!girls!enter!school!on!parity!with!boys,!girls!are!subject!to!higher!drop`out!rates.”1753,1754,1755!!!

D.&Education&quality&!The! quality! of! education! in! Haiti! occupies! a! large! spectrum,! ranging! from! a! small! number! of! private!schools! that! offer! international! standards! of! quality! to! the! vast! majority! of! schools! that! are!characterized!by!either!mediocre!or!poor!standards!of!education.!Those!schools!of!international!quality!are!available!only! to! the!wealthy.1756,1757,1758!Public! schools,!which!exist!mainly! in!urban!areas,! tend! to!occupy! the!middle! range! of! the! quality! spectrum.1759!Most! private! schools! can! be! broken! down! into!three! categories:! 1)! for`profit! entrepreneurial! schools! (ecoles& borlettes),! with! poorly! trained! teachers!and!staff!with!little!pedagogical!understanding,!2)!community!schools,!reliant!upon!the!community!for!financing,! with! low! fees! and! generally! low! quality,! and! 3)! Catholic! and! Evangelical! schools,! some! of!which!offer!high!quality!education,!and!are!generally!of!better!quality!than!other!private!schools.1760,1761!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1752!World!Bank,!A&review&of&gender&issues&in&the&Dominican&Republic,&Haiti&and&Jamaica,!Report!No.!21866`LAC!(2002).!Available!at!http://www`wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2003/03/22/000094946_03030704005682/Rendered/PDF/multi0page.pdf!!








1760!L.!Wolff,!Education&in&Haiti:&The&way&forward,!Partnership!for!Educational!Revitalization!in!the!Americas!(PREAL)!(September!2008).!Available!at!

!


In! general,! price! is! strongly! associated!with! quality,! with! the! result! that! students!who! cannot! access!subsidized!public!education!are!usually!forced!to!attend!low!quality!establishments.1762,1763!!The!greatest! impediment!to! increasing!the!quality!of!the!education!system!is!the! lack!of!qualified!and!experienced!teachers.1764,1765,1766,1767,1768!As!the!number!of!private!schools!increased!over!the!past!thirty!years!(see!Figure!117,!page!259),!the!high!demand!for!teachers,!in!conjunction!with!the!small!supply!of!qualified! personnel,! has! allowed! business! considerations! to! take! precedence! over! quality!standards.1769,1770!!!Several! studies,! for! example,! have! assessed! the! educational! attainment! of! teachers! in! the! public! and!private!sectors.!By!1996/97,!Hadjadj!found!that!only!15%!of!primary!school!teachers!held!a!professional!degree! (teaching! diploma! or! teacher! training! college! certificate),! while! another! 11%! had! completed!secondary! education.! As! such,! 74%! of! teachers! lacked! the! required! training! and! qualifications! to! be!eligible!to!teach,!while!25%!had!completed!nine!or!fewer!years!of!education!themselves.1771!A!UNESCO!assessment! in!1997!found!that!25%!of!11,500!teachers!surveyed!had!not!completed!the!nine!years!of!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!http://www.thedialogue.org/PublicationFiles/Education%20in%20Haiti%20`%20The%20Way%20Forward%20`%20FINAL%20`%209`15`08.pdf!!









Education!30/2!(2000),!pp.!163`178.!1769!UN!Committee!on!the!Rights!of!the!Child,!Consideration!of!reports!submitted!by!state!parties!under!article!44!of!the!Convention:!Haiti,!UN!Doc.!CRC/C/51/Add.7!(2002).!Available!at!http://www.unhcr.org/refworld/docid/3df59ad34.html!



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primary! education,1772!while! a! 1998! assessment! found! that! only! 10%! of! primary! school! teachers! had!graduated!from!a!teacher!training!college.1773!At!the!secondary!level,!data!from!1990!indicate!that!only!13.3%! of! secondary! teachers! held! an! education! diploma,! 18.2%! held! a! university! degree,! 47.9%! held!only!a!secondary!school!certificate,!and!20.6%!did!not!hold!any!of!these!qualifications.1774,1775!By!2006,!the!situation!of!teacher!qualification!had!deteriorated!further,!driven!by!the!continued!expansion!of!the!private!sector.!In!that!year,!only!21%!of!teachers!either!held!a!teaching!diploma!or!had!graduated!from!a!teacher!training!college.1776,1777!Lunde!has!noted!with!concern!that!teachers!have!often!“only!completed!a!few!grades!more!than!the!classes!they!are!teaching.”1778!!There! are! also! significant! differences! between! the! proportion! of! qualified! teachers! in! the! public! and!private!sectors.!In!1997,!UNESCO!found!that!47%!of!public!school!teachers!were!qualified,!holding!either!a!teaching!diploma!or!teacher!training!college!certificate,!while!only!8%!of!private!school!teachers!held!the! same!qualifications.1779,1780,1781! Salmi! attributes! this! disparity! to! the! fact! that!most! private! schools!pay! teachers! less! than! public! schools,! leading! qualified! teachers! to! work! for! the! public! sector! (see!below).1782!The!fact!that!the!number!of!private!schools!has!increased!significantly!over!the!period!since!this! survey!was! undertaken,!moreover,! suggests! that! the! proportion! of! teachers!who! are! adequately!











Education!30/2!(2000),!pp.!163`178.!1782!J.!Salmi,!“Equality!and!quality!in!private!education:!The!Haitian!paradox,”!Compare:&A&Journal&of&Comparative&

Education!30/2!(2000),!pp.!163`178.!

!


qualified,!especially!in!the!private!sector,!has!probably!decreased!further.1783!As!80%!of!Haitian!children!attend! private! schools,! it! becomes! clear! that! only! a! very! small! proportion! of! students! in! Haiti! are!educated!by!an!appropriately!qualified!teacher.!!In!addition!to!lacking!professional!training,!most!Haitian!teachers!lack!significant!teaching!experience.!In!1996/97,!Hadjadj! found!that!72%!of!Haitian! teachers!have! less! than!ten!years,!and!50%! less! than! five!years,!of!professional!experience.!Again,! this!proportion!was!higher! in! the!private!sector,!with!77%!of!teachers!having!taught!for!less!than!ten!years,!compared!to!47%!in!the!public!sector.1784!!Three!primary!factors!drive! low!rates!of!teacher!training!and!professional!experience.!First,!during!the!Duvalier!regimes,!significant!portions!of!the!educated!elite,!including!teachers,!escaped!to!the!U.S.!and!Canada,! creating! a! “brain! drain”! from! the! education! system.1785! Second,! education!management! and!supervision!systems!are!inadequate!or!non`existent,!resulting!in!late!payment!of!teacher!salaries,!poor!teacher! selection! processes,! and! lack! of! quality! assurance! monitoring.1786! Third,! and! perhaps! most!significantly,! is! the! low! wage! afforded! to! teachers,! especially! in! the! private! sector.! In! 2007,! public!primary! teachers! earned! approximately! 4,000! gourdes! (US$100)! per! month,! making! teaching!unattractive! for! the! educated! elite.! In! contrast,! private! rural! teachers! made! approximately! 1,500!gourdes! (US$38)! per! month,! or! 37.5%! of! their! public! sector! counterparts.1787,1788! Very! few! private!schools,! especially! those! in! rural! areas,! can! match! the! public! school! wage! and! attract! qualified!teachers.1789! As! a! result,! qualified! teachers! are! drawn! to! the! urban`based! public! sector,! while!unqualified!teachers!can!more!easily!find!work!in!the!private!sector.1790!!Low!wages!afforded!to!teachers!affect!not!only!the!quality!of!teachers,!but!also!the!quantity!of!teaching!hours!over!the!course!of!the!year.!Lunde!has!observed!that!teachers’!low!salaries!compel!many!teachers!









Education!30/2!(2000),!pp.!163`178.!

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to!undertake!other! income`generating!activities.!Many! teachers,!particularly! those! in! rural!areas,!may!be! absent! from! the! classroom! for! weeks! or! months! at! a! time,! particularly! during! the! sowing! and!harvesting!seasons.1791!Additionally,!private!schools! rely!on! fees!paid!by! families! to!pay! teachers.!As!a!significant! proportion! of! students! drop! out! during! the! year,! shortfalls! in! revenue!may! prevent! them!from!paying!teachers!on!time.!Some!teachers!“stay!away!for!a!while!to!put!pressure!on!the!directors!to!provide!their!pay.”1792! In!the!public!sector,!ongoing!disputes!between!Haiti’s! five!teachers’!unions!and!the! government! have! provoked! strikes! and! even! more! teacher! absenteeism.1793! Such! disruptions! in!schooling,!whether!from!teachers’!need!to!supplement!their! income!or!to!pressure!school!directors!or!the! government,! curtail! the! ability! of! students! to! receive! instruction! that! could! help! them!pass! their!exams! and! proceed! to! the! next! level.! Students! failing! to! pass! these! end`of`year! exams! must! either!repeat!the!grade!or!drop!out!of!school,!with!the!associated!consequences!for!their!individual!futures!as!well!as!those!of!their!families,!who!have!a!large!financial!stake!in!their!schooling.!!Once! in! the! classroom,! students! continue! to! face! impediments! to! their! learning!due! to!overcrowding!and! poor! student`teacher! ratios.1794,1795! In! 2006,! the! World! Bank! estimated! that! there! were!approximately!46!students!for!every!teacher!in!Haiti.1796!However,!the!IMF!has!estimated!the!ratio!to!be!much!higher,!at!one!teacher!per!78!students.1797!The!cause!of!the!wide!discrepancy!between!estimates!is! unclear.! However,! both! the! Haitian! government! and! the! International! Financial! Institutions! (IFIs)!believe!that!the!degree!of!overcrowding!in!Haitian!schools!undermines!learning.1798,1799,1800! In!addition,!











!


the!Haitian!Ministry!of!Education,!Youth!and!Sports!notes!that!the!presence!of!over`age!students!in!the!class! worsens! the! situation,! as! teachers! must! try! to! adapt! their! didactic! strategy! for! an! audience!spanning!five!or!six!years.1801!!Little! information!exists!regarding!the!quality!of!tertiary!education,! including!universities!and!technical!and! vocational! schools.! Wolff! has! reported! that! most! technical! and! vocational! schools! have! little!equipment,! limiting! their! didactic! potential.1802! Additionally,! these! schools! are! accessible! only! to! a!minority!of!students,!and!are!generally!of!very!low!quality,!meaning!that!even!those!students!who!are!admitted!receive!little!benefit.1803!The!IMF!has!criticized!Haiti’s!higher!education!sector!for!its!role!in!the!perpetuation! of! gender! stereotypes! and! discriminatory! teacher! training,! which! may! be! seen! as! one!factor! among!many! leading! to! an! unequal! gender! balance! among! those! attending! schools! of! higher!education.1804!Haiti’s!higher!education!system!thus!performs!poorly!not!only! in!terms!of!the!education!provided! to! students,! but! also! in! terms! of! its! impact! on! social!mobility! and! societal! relations! due! to!unequal!access!between!men!and!women.!!Haitian!schools!are!characterized!by!chronic!shortages!of!infrastructure!as!well,!including!both!basic!and!teaching! facilities.1805! In! 2003,! it! was! estimated! that! roughly! 5%! of! schools! were! based! in! a! church!building! or! under! a! shaded! open`air! area,1806! a! reduction! from! 7%! estimated! in! 2000.1807! These! and!other! poorly! constructed! schools! are! particularly! vulnerable! to! natural! hazards,! particularly! recurrent!hurricanes! and,! as! tragically! witnessed! in! January! 2010,! earthquakes.1808! School! closings! due! to!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1800!Haitian!Ministry!of!Education,!Youth!and!Sports,!The&problem&of&over5age&students&in&the&Haitian&education&








Education!30/2!(2000),!pp.!163`178.!1806!Technical!Secretariat!of!the!Preparatory!Committee,!Growth&and&poverty&reduction&strategy&paper:&Republic&of&Haiti.!IMF!country!report!08/115!(November!2007).!Available!at!http://www.imf.org/external/pubs/ft/scr/2008/cr08115.pdf!


1808!L.!Wolff,!Education&in&Haiti:&The&way&forward,!Partnership!for!Educational!Revitalization!in!the!Americas!(PREAL)!(September!2008).!Available!at!

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rebuilding!and!repairs! further!deprive!children!of!classroom!time,!reducing!their!ability!to!pass!annual!exams.1809,1810!!Further! restricting! children’s! learning!potential,!most! schools! also! lack!basic! learning! facilities! such! as!libraries,! playing! fields,! and! even! electricity! in! the! classroom.1811! In! 2000,! only! 21%! of! schools! were!electrified,! 12%! included! a! playing! field,! and! only! 8%! had! a! library.1812! In! 2008,!Wolff! reported! that!public! high! schools! in! Haiti! lack! laboratories! or! libraries,1813! although! the! IMF! estimated! that! 36%! of!schools!(including!private!schools)!do!have!libraries.1814!!!Access!to!high!quality!learning!materials!in!Haiti!is!very!low!as!well.1815!Although!access!to!textbooks!is!a!right! guaranteed! under! the! Constitution,!many! children! are! unable! to! access! them.1816! In! some! high!schools,!Wolff!reports!that!the!teacher!may!be!the!only!person!in!the!classroom!with!a!textbook.1817!In!addition! to! a! lack! of! access,! a! review! by! the! Ministry! of! Education! in! 2000! also! found! that! a! large!proportion!of!textbooks!that!are!available!are!of!low!quality:!

!A!vast!amount!of!teaching!and!learning!material!is!produced!in!Haiti!itself.!In!addition!to!manuals!produced! by! the! Frères! de! l’Instruction! Chrétienne! and/or! the! Henri! Deschamps! Publishing!Company,!many!books!are!produced!by!individual!teachers!who,!after!a!certain!number!of!years,!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!http://www.thedialogue.org/PublicationFiles/Education%20in%20Haiti%20`%20The%20Way%20Forward%20`%20FINAL%20`%209`15`08.pdf!!









Education!30/2!(2000),!pp.!163`178.!1817!L.!Wolff,!Education&in&Haiti:&The&way&forward,!Partnership!for!Educational!Revitalization!in!the!Americas!(PREAL)!(September!2008).!Available!at!http://www.thedialogue.org/PublicationFiles/Education%20in%20Haiti%20`%20The%20Way%20Forward%20`%20FINAL%20`%209`15`08.pdf!!

!


offer!the!fruit!of!their!experience!to!their!colleagues!and!students.!This!situation!explains!why,!in!many!cases,!the!quality!of!textbooks!is!so!poor.1818!

!Lack!of!supervision!and!quality!control!of!teaching!materials!and!curriculum!development!is!endemic!to!the!Haitian! education! system.!A! 2008! study! found! that! national! quality! control! agencies,! such! as! the!National! Institute! for! Professional! Training! and! the! National! Pedagogical! Institute,! fail! to! fulfill! their!purpose!or!no!longer!exist.1819!As!a!result,!teachers!(especially!private!school!teachers)!are!not!reviewed!according! to! the! quality! of! their! instruction! and! receive! little! official! guidance! on! expectations! for!curricula.! In!many! ways,! this! lack! of! quality! control! can! be! attributed! to! deficiencies! in! the!Ministry!workforce;!tellingly,!each!school! inspector!was!responsible!for!approximately!200!schools! in!2000—far!too!high!of!a!number.1820!!!In!addition!to!improving!access!to!education,!the!response!to!the!2010!earthquake!has!also!prioritized!improving! the! quality! and! availability! of! teaching! materials,! and! replacing! learning! materials.1821! Six!months! after! the! earthquake,! approximately! 501,000! children! had! been! provided! with! learning!materials! by! Education! Cluster! partners.1822! However,! a! countrywide! survey! conducted! by! the! MIT!Lincoln! Laboratory! and! Harvard! Medical! School! in! April! 2010! found! very! low! coverage! of! education!materials! across!Haiti.! Of! all! cities,! children! of! Les! Cayes! had! the! greatest! access,!with! just! over! 50%!declaring!that!they!had!access!to!educational!materials.1823!A!further!study!in!earthquake`affected!areas!conducted!in!June!found!that!65%!of!families!reported!that!none!of!their!children!had!access!to!learning!materials,!while!only!17%!reported!access!for!some!of!their!children,!and!18%!reporting!that!all!children!in!the!household!had!learning!materials.1824!By!March!2011,!the!Education!Cluster!reported!that!850,000!children! had! benefited! from! the! distribution! of! learning!materials.1825! In! light! of! initiatives! to! expand!access! to! and! engagement! with! the! educational! system,! the! Education! Cluster! has! highlighted! the!







1823!UN!OCHA!Haiti,!Haiti:&Humanitarian&assessment&key&findings&No.&4&(April!2010).!1824!Global!Relief!Technologies,!Haitian&field&assessments:&US&Agency&for&International&Development&weekly&data&

analysis&for&the&week&of&June&14,&2010!(June!2010).!1825!Global!Education!Cluster,!Global&education&cluster&update:&January&5&March&2011,!Global!Education!Cluster!(2011).!Available!at!http://oneresponse.info/GlobalClusters/Education/publicdocuments/Education%20Cluster%20Update_January_March_2011_FINAL.pdf!

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pressing! need! to! deliver! learning! materials! to! meet! the! needs! of! increased! numbers! of! school!enrollees.1826!!!Similar! to! didactic! facilities,! many! schools! are! not! equipped! with! adequate! sanitation! and! hygiene!infrastructure.! In! 2000,! UNESCO! found! that! 67%! of! schools! had! toilet! facilities,! while! only! 42%! had!running! water.1827! In! 2007,! the! IMF! reported! significantly! different! findings,! stating! that! 58%! lacked!toilet! facilities,! while! only! 23%! lacked! running! water.1828! Lack! of! sanitary! conditions! may! be! a!disincentive! for! families! to! send! their! children! to! school.! While! lack! of! appropriate! sanitation!infrastructure!has!been!seen!to!exclude!girls!from!the!education!system!in!many!contexts,!it! is!unclear!whether!this!concern!carries!similar!weight!in!Haiti.!!A!March!2010!survey!conducted!by!the!Ministry!of!Education! in!earthquake`affected!areas!found!that!young!people! identified!water! and! sanitation! access! in! schools! as! a!major! priority.1829,1830!A! survey!of!thirty!schools!in!earthquake`affected!areas!conducted!by!Feed!the!Children!in!mid`2011!found!that!60%!of! surveyed! schools! lacked! water! for! students! to! wash! their! hands,! 23%! of! schools! had! appropriate!facilities! to! treat! and! store!water,! and!only!13.3%!of!had!hygienic! latrines!available.1831! Particularly! in!light!of!Haiti’s!cholera!epidemic,!poor!access!to!water,!sanitation,!and!hygiene!in!schools!is!of!particular!concern! to! the! protection! of! children’s! rights! and! basic! needs,! and! is! discussed! in! further! detail! in!Section!6C.&Water,&sanitation,&and&hygiene.!!More! positively,! Haiti! has! made! great! strides! in! increasing! literacy! over! the! past! forty! years! despite!these!and!the!other!problems!of!educational!engagement!noted!above.!Between!1970!and!2000,!adult!(over!age!15)! illiteracy! fell! from!78%!to!39.5%,!a!reduction!of! roughly!50%!(Figure!129).1832!This! fall! in!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1826!Haiti!Education!Cluster,!Education&cluster&situation&report:&11&July&2011!(July!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/reports/juillet%202011/Education_Cluster_SitRep_11072011.pdf!!





1831!Haiti!Education!Cluster,!Education&cluster&situation&report:&8&August&2011!(August!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/reports/Aout%202011/Education_Cluster_SitRep_080811.pdf!


!


illiteracy! was! greater! for! men! (54.9%! reduction)! than! for! women! (47.2%! reduction);! in! fact,! female!illiteracy!has!fluctuated!greatly!over!the!years,!and!actually!increased!in!the!period!1995`2000.1833!!!Figure.129:.Adult.illiteracy.in.Haiti,.by.year.and.sex,.1970T2000.



!!Since! 2000,! the! adult! illiteracy! rate! has! continued! to! fall! for! both!men! and! women.! The! EMMUS! IV!survey!revealed!that!by!2006,!a!greater!proportion!of!women!were! literate! (64%)!than!men!(61%).1834!According! to! the! UNDP,! 62.1%! of! adult! Haitians! overall! were! literate! in! 2006,!while! 37.9%! remained!illiterate.1835!!Decreases! in!adult! illiteracy!have!been!driven!by! increases! in! literacy!among!youth!(those!aged!15`24,!defined! as! youth!by! the!UN).! Between!1990! and!2006,! the! literacy! rate! among! youth! rose!by! 50.3%,!from!54.8%!in!1990!to!82.4%!in!2006.!Prior!to!the!2010!earthquake,!Haiti!was!therefore!on!track!to!meet!Millennium! Development! Goal! 2.3! of! reaching! universal! literacy! for! this! age! group! by! 2015! (Figure!130).1836! The! IMF!also! estimated! that! there!was! approximate! gender!parity! for! youth! literacy! in! 2005!(Gender!ratio:!0.95).1837!!







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8.&Education&


Figure.130:.Progress.towards.MDG.2.3.(universal.youth.literacy),.1990T2015.


!!While! the!2005/06!EMMUS! IV! survey! indicated!a! significant! increase! in! youth! literacy! in!Haiti!overall,!significant!differences!exist!between!Departments!and!between!urban!and!rural!areas!(Figure!131).1838!The!Port`au`Prince!metropolitan!area!recorded!the!highest!prevalence!of! literacy!among!female!youth!aged!15`19!and!20`24,!at!91.7%!and!92.3%,!respectively.! In!contrast,!the!Centre!Department!recorded!the! lowest! literacy! prevalence! among! female! youth! in! both! age! groups,! at! 38.2%! and! 47.3%,!respectively.!Illiteracy!among!rural!adolescent!girls!aged!15`19!was!more!than!twice!that!of!their!urban!peers!(24%!and!11.3%,),!while!it!was!three!times!more!prevalent!in!those!aged!20`24!(29.8%!vs.!9.9%,!rural!and!urban).!!



!


Figure.131:.Illiteracy.among.female.youth,.by.Department,.2006.



!!Inclusion!of!young!people!aged!10`14!decreases!estimates!of!the!prevailing!literacy!rate.!Overall,!Lunde!found!that! in!2009,!approximately!half!of! the!population!aged!10`24!was! literate,!or!78%! if! the!partly!literate! were! included.! Among! this! population,! Lunde! found! similar! differences! between! the! literacy!rates!of!urban!and!rural!young!people,!noting!that!two!thirds!of!urban!young!people!were!literate!(not!including!the!partially!literate)!compared!to!only!one!third!of!rural!young!people.1839!!!!

E.&Access&to&education&and&barriers&to&enrollment&!Three! major! barriers! restrict! Haitians’! access! to! education:! the! lack! of! absorptive! capacity! of! the!education!system,!the!cost!associated!with!enrollment!and!examinations,!and!the!physical!distance!to!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1839!H.!Lunde,!Haiti&youth&survey&2009&5&Volume&I:&Tabulation&report,!Fafo!report!2009/53!(2009).!Available!at!http://www.fafo.no/pub/rapp/20143/20143.pdf!

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8.&Education&


schools.!This!section!will!consider!these!three!barriers!in!turn,!before!concluding!with!an!assessment!of!the!impact!of!the!January!2010!earthquake!on!education!access.!&

The!Haitian!education!system’s!lack!of!capacity!to!absorb!prospective!entrants!must!be!dissected!along!four!lines.!First,!the!absolute!shortage!of!public!school!places!requires!the!majority!of!the!population!to!look! to! the!private! sector! for! education.! Second,! repeating! and! late`entry! limit! the!number!of! school!places!available!to!new!entrants!even!further.!Third,!the!concentration!of!schools!in!urban!areas!results!in!unequal!access!between!urban!and!rural!children.!Fourth,!the!reduction!in!the!proportion!of!schools!offering!two!or!more!cycles!of!education!forces!exclusion!at!higher!education!levels.!!As!a!Constitutional!right,!the!responsibility!to!provide!nine!years!of!free!education!to!all!Haitians!falls!to!the! state.! However,! only! 8%! of! all! primary! and! secondary! schools! in! Haiti! are! public,! educating!approximately!20%!of!all!Haitian!students.1840,1841,1842,1843!This!inadequacy!of!resources!and!infrastructure!forces!most!prospective!students!to!turn!to!the!private!sector.!In!fact,!competition!to!attend!the!limited!public!schools,!which!are!generally!more!affordable!than!private!schools,!has!increased!to!such!a!degree!that!new!entrants!are!often!required!to!know!how!to!read!and!write!before!they!enter!the!first!grade.!This!reality!forces!those!who!have!not!attended!private!pre`schools!to!pay!for!private!education.1844!As!shown! earlier! (Section! 8B.& Formal& education& system),! the! number! of! private! schools! has! increased!dramatically! over! the! past! two! decades,! but! the! overwhelming! majority! of! these! schools! are!unlicensed.1845,1846!Despite!this!expansion,!moreover,!the!private!education!system!has!been!unable!to!provide!sufficient!classroom!seats!to!meet!the!demand!of!both!new!entrants!and!repeating!students.!As!such,! the! state! has! been! unable! to! fulfill! its! Constitutional! responsibility! either! directly,! through! the!provision! of! public! education,! or! indirectly,! through! the! creation! of! equitable! systems! for! access! to!private!sector!schools.!!







Education!30/2!(2000),!pp.!163`178.!1845!Haiti!Education!Cluster,!Education&cluster&bulletin:&18&February&2010!(February!2010).!Available!at!http://oneresponse.info/Disasters/Haiti/Education/Documents/ECU!English.docx!!


!


The! impact! of! late! entry! and! repeating! students! on! the! absorptive! capacity! of! the! Haitian! education!system! is! immense! as!well.! As! discussed! above! in! Section!8C.& Education& engagement,! almost! 80%! of!students!in!the!first!grade!in!1996/97!were!over!the!official!age!for!that!level,!either!because!they!had!entered! the! system! late,! or! because! they! had! been! forced! to! repeat! the! first! grade.! These! students!strain! the! education! system!because! they!occupy! classroom! seats! that! could! otherwise! have! gone! to!new! entrants.! As! noted! previously,! without! the! issues! of! repeating! and! late`entry! students,! the!education!system!(private!and!public,!combined)!would!have!excess!capacity!after!accepting!all!children!of!the!correct!age!for!the!first!grade.1847!!Schools! and! school! places! are! unequally! distributed! across!Haiti,!with!most! schools! (especially! public!schools)!located!in!urban!areas.!While!the!number!of!available!school!places!is!inadequate!everywhere,!the!problem!is!worse! in!rural!areas! in!both!a!quantitative!and!qualitative!sense.! In!2000,!35%!of!rural!classrooms! reported! a! shortfall! of! ten! or! more! places,! compared! to! 24%! of! classrooms! in! urban!areas.1848!Rural!children!are!particularly!vulnerable!to!the!education!system’s!lack!of!absorptive!capacity!both!because! the!number!of! seats!available! is!proportionally! smaller!and!because! failure! to! receive!a!place!in!one!school!has!a!relatively!greater!impact!on!the!ability!to!access!any!formal!education!at!all.!An!urban!child!who!is!denied!a!place!at!the!nearest!primary!school,!after!all,!may!be!able!to!find!a!place!at!another! relatively! proximate! school;! in! contrast,! rural! children! denied! places! at! a! nearby! school! are!more!likely!not!to!attend!school!at!all!given!to!the!longer!journey!required.1849,1850!!!While!the!growth!of!private!schools!has!quelled!the!shortage!spaces!in!the!first!cycle!of!basic!education!over! the!past! thirty! years,!unmet!demand! for! the! second!and! third! cycles!has! intensified.!This!unmet!demand!can!be!conceived!as!the!proportion!of!students!who!complete!the!first!cycle!of!basic!education!who! would! enter! the! second! and,! eventually,! third! cycle! of! education! if! spaces! were! available.! The!proportion!of!schools!offering!both!the!first!and!second!cycle!has!fallen!over!time.!In!2000,!only!50%!of!schools!across!Haiti!offered!both!the!first!and!second!cycles,!and!this!proportion!was!even!lower!in!rural!areas,!at!43%.1851!As!a!result,!a!smaller!percentage!of!first!cycle!graduates!can!continue!on!to!the!second!cycle.!!!







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Lack!of!available!school!places!is!even!greater!as!students!enter!the!third!cycle!of!basic!education!(the!start!of!secondary!education)!and!continue!to!higher!studies.!Over!time,!demand!for!secondary!school!has! increased,! while! capacity! has! stagnated.1852! In! 2004,! only! 66.8%! of! applicants! to! the! third! cycle!received! a! space! due! to! the! limited! absorptive! capacity! of! the! system! at! this! level.1853! At! the! higher!education! level,!only!55.5%!of!all!15,500!new!applicants!were!able!to!be!accepted,!with!2,300!gaining!acceptance! to! the! state! university,! while! double! that! number! were! accepted! into! private! higher!education!providers.1854!!!Insufficient!absorptive!capacity!in!the!Haitian!education!system!leads!to!distortions!of!access.!In!addition!to!the!urban/rural!disparity!discussed!above,!many!parents!also!believe!that!personal!connections!are!required!to!secure!a!school!place! for! their!child.1855!As!Lunde!noted! in!2008,!“with!a!high!demand!for!school!places,!the!ability!to!pay!school!fees!and!additional!costs!are!in!many!cases!not!enough.!Personal!connections! are! also! necessary.! Several! of! the! people! we! interviewed! stressed! the! importance! of! a!marraine!or!a!parrain!in!order!to!make!sure!that!one’s!child!will!get!one!of!the!few!available!chairs!in!the!class!room.”1856!!Moreover,! the! high! demand! for! public! school! places! encourages! the! abandonment! of! policies!guaranteeing! automatic! progression!within! cycles.! Due! to! high! demand,! some!public! school! directors!dismiss! failing! students! so! that! another,! perhaps! more! gifted,! child! can! use! the! newly! available!classroom!space.1857!Lack!of!capacity,!then,!fosters!a!culture!of!rule`breaking!with!impunity,!while!failing!to!provide!better!student!outcomes.!!The! greatest! barrier! to! education! in! Haiti,! itself! a! symptom! of! the! system’s! inadequate! absorptive!capacity,! is!that!of!cost.1858,1859,1860!As!demand!for!a!place!in!school,!and!particularly!a!place!in!a!public!school,! is! greater! than! the! supply,! the!private! sector!may! charge! fees! that! are!out!of! reach! for!many!Haitians!while!still!filling!class!quotas.!For!other!schools,!the!fees!required!of!families!to!pay!teacher!and!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1852!V.!Jules!and!A.!Panneflek,!Subregional&synthesis&report:&Volume&I&5&Summary,!Education!for!all!in!the!Caribbean:!Assessment!2000!(2000).!Available!at!http://www.unesco.org/carneid/synthesis`1.pdf!!









!


staff! salaries!may!still!be!prohibitive.1861!The! IMF!notes! that! this!demand`driven!market! for!education!reinforces! inequality,!excluding!many,!and!providing!only!poor!quality!education! for! the! impoverished!majority! of! Haiti’s! population.1862! Roughly! 43%! of! families! with! children! who! are! not! in! school! cite!financial! costs! as! the! primary! barrier! to! enrolling! their! children,1863! as! do! 74.3%! of! families! whose!children!were!in!school!but!have!since!dropped!out.1864!Similarly,!66%!of!students!who!begin!education!but!do!not!graduate!cite!high!education!costs!as!the!primary!reason.1865!!While! significantly! lower! than! the! cost! of! sending! a! child! to! a! private! school,! families! enrolling! their!children! in! public! education!must! still! spend! a! large! part! of! their! income! on! ancillary! costs,! such! as!uniforms,!books,!other!learning!materials,!and!a!required!contribution!of!50!Haitian!gourds!(US$2)!per!year.1866! This! sum! already! places! education! outside! the! reach! of!many! children.1867! Lunde! notes! that!textbooks! for! each! grade! easily! cost! more! than! 1,000`2,000! gourdes,! equaling! roughly! 10%! of! the!average!annual!household!income!per!child!enrolled.!In!2002,!UNDP!estimated!that!the!average!cost!of!basic!education!per!grade!was!approximately!1,600!gourdes!(US$64).1868!Accounting!for!inflation!and!the!proportion! of! students! attending! public! schools,! this! finding! is! roughly! consistent! with!Wolff’s! 2008!finding! that! private! primary! school! tuition! costs!US$85! per! annum,! rising! to!US$135! once! books! and!uniforms! are! taken! into! account.1869! Although! 92%! of! the! population! lives! within! 30! minutes! of! the!nearest! primary! school,! many! are! unable! to! attend! this! proximate! school! due! to! lack! of! capacity!(discussed!above)!or!prohibitive!cost.!Cost!may!dissuade!such!families!from!sending!their!child!to!school!because!they!are!unable!to!afford!the!school!fees!at!the!nearest!school,!while!the!next!nearest!option!may!be!too!expensive,!lacks!capacity,!or!be!too!far!away.1870!The!disincentive!created!by!school!fees!is!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1861!H.!D.!Nielsen,!Moving&towards&free&primary&education:&Policy&issues&and&implementation&challenges&5&A&state&of&





1864!G.!Previlon,!Community&youth&mapping&report,!IDEJEN!&!USAID!(August!2004).!Available!at!http://www.equip123.net/docs/e3`CommunityYouthMappingReportHaiti.pdf!!




1868!UNDP!Haiti!Country!Office,!Rapport&national&sur&le&développement&humain&2002&(Haiti&national&human&

development&report):&La&bonne&gouvernance:&Un&defi&majeur&pour&le&developpement&humain&durable&en&Haiti!(2002).!Available!at!http://www.ht.undp.org/public/publicationdetails.php?idpublication=11!!



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8.&Education&


even!more!pressing!at! the! secondary! level,!where! the!UNDP! found! school! fees! to!be!almost! twice!as!high!as!those!charged!for!basic!primary!education,!at!an!average!of!3,070!gourdes!per!year.1871,1872!!Education!represents!a!significant!proportion!of!household!expenditure.!For!the!poorest!quintile!in!Haiti,!enrollment! of! one! child! represents! 15`25%! of! household! income,! with! those! in! rural! areas! typically!spending! a! higher! proportion! of! household! income! on! education! than! their! urban! counterparts,! and!those!with!a!child!in!public!education!occupying!the!lower!end!of!this!range.1873,1874!Poor!families!simply!lack! the! means! for! such! an! outlay! and,! as! a! result,! are! the! least! likely! to! enroll! their! children! in!school.1875!In!contrast,!educational!expenses!constitute!3`4%!of!household!income!in!other!low`income!countries.1876!!At!the!same!time,!poor!families’!willingness!to!spend!significant!proportions!of!their!limited!income!on!their! children’s! education! testifies! to! the! priority! afforded! to! education! in! Haiti;1877! in! fact,! many!struggling!families!spend!their!entire!savings!on!educating!their!children.1878!These!families!show!a!high!propensity! to! consume! education,! with! diminishing!marginal! returns.!When! provided!with! additional!income,! lower! income!households!are! likely! to!prioritize!education!expenditure!over!other!goods!and!services.! In!2009,! the! IMF!found!that!23.9%!of!all! remittance!and!other!transfer! income!was!spent!on!education,! second! only! to! consumption! of! food! and! clothing! (47.3%),! and! approximately! three! times!more! than! the! proportion! spent! on! households’! fourth! priority,! housing! construction! and! repair!(8.2%).1879!!!Moreover,!the!financial!ability!of!some!households!to!enroll!their!children!in!school!is!often!determined!more!by!access!to!credit! than!aggregate!household! income.! In!rural!areas,!households!typically!derive!much!of!their! income!following!the!harvest! in!October.!However,!school!fees!for!the!year!are!typically!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1871!UNDP!Haiti!Country!Office,!Rapport&national&sur&le&développement&humain&2002&(Haiti&national&human&

development&report):&La&bonne&gouvernance:&Un&defi&majeur&pour&le&developpement&humain&durable&en&Haiti!(2002).!Available!at!http://www.ht.undp.org/public/publicationdetails.php?idpublication=11!!









!


paid! in! September,!when!households! have! not! yet! reaped! the! benefits! of! their! harvest.1880! Access! to!short`term!credit!may!provide!these!families!with!a!means!to!enroll!their!children!in!school!before!the!harvest!one!month!later.!!When!household!income!quintiles!are!assessed!in!aggregate!across!Haiti,!increased!income!is!positively!associated!with!the!probability!that!children!will!be!enrolled!in!basic!education!(Figure!132).1881!A!child!in! a! household! in! the! richest! quintile! is! 18.5%! more! likely! (87.2%)! to! be! enrolled! than! a! child! in! a!household! in! the! poorest! income! quintile! (73.6%).! However,! this! is! not! true! for! Port`au`Prince!metropolitan!area!and!urban!households!considered!separately,!with!the!greatest!probability!of!a!child!being!in!school!seen!in!the!third!and!fourth!income!quintiles,!respectively.1882!Children!in!rural!areas!are!less!likely!to!be!attending!school!in!all!income!quintiles,!as!would!be!expected!given!that!the!proportion!of!people!living!in!poverty!in!rural!areas!(82%!in!2007)! is!higher!than!in!the!metropolitan!area!(41%!in!2007).!!Figure.132:.School.attendance.of.7T14.yearTolds,.by.income.quintile,.2001.


!!With!such!a!large!proportion!of!household!expenditure!at!stake,!and!with!such!high!repetition!and!drop`out!rates!(see!Section!8C.&Education&engagement),!families!are!cognizant!of!the!risk!involved!in!enrolling!a!child!in!school.!The!decision!to!send!a!child!to!school!is!influenced!by!the!perceived!likely!returns!from!the! investment,! in! addition! to! the! opportunity! cost! of! enrolling! a! child! (for! example,! potential! lost!productivity!from!agriculture!due!to!the!child’s!absence).1883!This!decision!is!especially!important!in!rural!and! poor! households.! Both! of! these! categories! are! vulnerable! to! external! shocks,! such! as! a! failed!harvest,! medical! costs,! or! unemployment.! Lacking! economic! buffers! such! as! savings,! insurance,! or!welfare!benefits,!these!populations!rely!on!favorable!external!factors!to!support!their!child’s!enrollment.!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1880!H.!Lunde,!Youth&and&education&in&Haiti:&Disincentives,&vulnerabilities&and&constraints,!Fafo!paper!2008/26!(2008).!Available!at!http://www.fafo.no/pub/rapp/10070/10070.pdf!!




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8.&Education&


If!these!circumstances!change,!poor!and!rural!households!will!be!caught! in!an!“investment!trap”:!they!have!already!spent!a!significant!proportion!of!their!income!on!school!fees!and!ancillary!costs!but!will!not!reap!any!benefits!because!the!child,!unqualified!to!move!up!to!the!next! level,!drops!out!of!school.1884!Many!families!utilize!livestock!as!a!source!of!savings,!selling!an!animal,!for!example,!at!the!start!of!the!school!year!to!pay!the!upfront!costs!of!enrollment.!If!circumstances!change,!the!family!has!lost!both!the!ability! of! their! child! to! proceed! in! grade! the! next! year,! and! the! savings! invested! in! the! animal.1885! In!contrast! to! rural! families,! school! directors! reported! that! dropouts! in! urban! areas! were!more! usually!related!to!idiosyncratic!changes,!such!as!a!death!in!the!family.1886!!Endòf`year!exam!fees!play!a! substantial!part! in! the!“investment! trap”!as!well.!Having!studied! for! the!year,!many! students!are! required! to! sit! an!endòf`year!exam!to!progress!within!a! cycle,! an! illegal!but!common!practice.! For! progression! between! cycles,! these! exams! are! legal! and!mandatory.! Inability! or!unwillingness! to! pay! endòf`year! exam! fees! negates! a! student’s! ability! to! progress,! forcing! them! to!either!repeat!the!same!year!again!or!drop!out!of!school!entirely.!Parents!have!cited!these!fees,!and!the!risk!of!not!being!able!to!pay!them,!as!a!severe!disincentive!to!enrolling!their!children!in!school!at!all.1887!!Faced!with!the!high!cost!of!education,!and!to!mitigate!the!risk!of!an!“investment!trap,”!many!families!employ!one!of!two!coping!strategies.!The!majority!of!families!whose!children!are!not!all!in!school!have!decided! to! support!one!or! some!of! their! children! to!progress! as! far! through! the!education! system!as!possible,!while!the!other!children!either!work!at!home,!migrate!in!search!of!work,!or!stay!with!another!family.!A!smaller!group!of! families!alternate!the!enrollment!of!their!children! in!school,!contributing!to!the!issue!of!overàged!students.!For!these!children,!their!families,!and!the!education!system!as!a!whole,!neither!of!these!strategies,!while!uncomfortable!realities,!are!desirable.1888!!To!address! the! impact!of! financial! barriers!on! children’s! access! to!education,! the!Haitian! government!has! conducted! various! pilot! projects! seeking! to! support! families! who! are! unable! to! pay.! In! 2000,! a!coalition!of!national! educational! authorities,! churches,!NGOs!and!private! schools!provided! support! to!17,000!children!in!the!Centre!Department,!allowing!them!to!attend!school.1889!In!2007,!56,823!children!in! eight! Departments! benefited! from! the! Education! for! All! program! that! provided! schools! with! a!capitation! grant! of! $90! per! student,! intended! to! continue! through! 2017.! Although! families!were! still!responsible! for! the! costs! of! uniforms! and! transport,! the! subsidy! provided! significant! financial!



Education!30/2!(2000),!pp.!163`178.!1886!H.!Lunde,!Youth&and&education&in&Haiti:&Disincentives,&vulnerabilities&and&constraints,!Fafo!paper!2008/26!(2008).!Available!at!http://www.fafo.no/pub/rapp/10070/10070.pdf!!



1889!UN!GA,!Situation!of!human!rights!in!Haiti,!UN!Doc.!A/55/335!(2000).!Available!at!http://www.un.org/documents/ga/docs/55/a55335.pdf!

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relief.1890,1891!The!program!acknowledged!concerns!that!grants!directly!to!families!may!instead!be!used!for! purchasing!more! land,!machinery! or! other! laborìntensive! inputs! that!may! actually! reduce,! rather!than!increase,!the!propensity!of!families!to!enroll!their!children!in!school.1892!Other!small`scale!programs!have!also!been!initiated,! including!a!similar!capitation!grant!scheme!in!the!Nippes!Department!funded!by!the!World!Bank,!and!radio!education!programs.1893!However,!this!Report!did!not!find!any!evaluations!of!these!programs,!nor!updates!regarding!their!current!status.!!The!third!major!factor!limiting!access!to!education!in!Haiti!is!the!distance!students!must!travel!to!attend!school.!Although!also!a!concern!in!urban!areas!due!to!a!lack!of!economic!access!to!proximate!schools,!distance! is! a! more! significant! barrier! for! children! in! rural! areas.1894! As! noted! previously,! 92%! of! the!population! has! a! school! within! half! an! hour’s! walking! distance.! However,! a! combination! of! lack! of!capacity!and!cost,!especially!when!it!is!considered!that!most!public!schools!are!located!in!urban!areas,!may! force! families! to! search! for! educational! opportunities! for! their! children! farther! afield.! Lunde!has!suggested! that! the! distance! to! schools! in! rural! areas!may! contribute! to! high! dropòut! rates! and! late!enrollment,!as!students!tire!of!traveling!such!long!distances,!and!parents!may!not!want!their!six!yearòld!children! walking! long! distances! to! attend! classes.1895! In! 2008,! the! IMF! found! that! there! were! 145!communal!sections!that!did!not!contain!a!public!school,!and!23!that!contained!no!school!at!all.1896,1897!!Lack!of!proximity!to!schools!intensifies!as!students!seek!to!enroll!in!secondary!and!tertiary!education.!In!2000,!it!was!found!that!only!28%!of!households!in!rural!areas!had!a!secondary!school!within!5!km,!while!26%!had!to!travel!more!than!15!km!to!attend!a!secondary!school.!Children!consequently!often!have!to!move!to!cities!and!towns!to!attend!secondary!education.1898!At!the!tertiary! level,!very!few!institutions!exist!outside!urban!areas,!necessitating!relocation!for!rural!and!semi`rural!students.!This!is!also!true!of!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1890!IMF,!Haiti:&Poverty&reduction&strategy&paper,!IMF!country!report!No.!09/290!(2009).!Available!at!http://www.imf.org/external/pubs/ft/scr/2009/cr09290.pdf!!









1897!Haiti!Education!Cluster,!Education&cluster&situation&report:&11&July&2011!(July!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/reports/juillet%202011/Education_Cluster_SitRep_11072011.pdf!!


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8.&Education&


training!centers,!making!any!form!of!tertiary!education!extremely!difficult!to!access!for!the!vast!majority!of!rural!Haitians.1899!!The! January! 12,! 2010! earthquake! both! provided! new! barriers! to! children’s! access! to! education,! and!exacerbated! pre`existing! constraints.! Approximately! 23%! of! all! schools! in! Haiti! (4,992)! were! either!damaged!or!destroyed!as!a!result!of!the!earthquake,!and!1,527!teaching!and!educational!personnel!lost!their! lives,1900,1901,1902,1903! reducing! the! absolute! number! of! school! places! available.! As! noted! above,!however,!in!2011!significant!and!rapid!progress!was!made!transitioning!from!the!distribution!of!tents!to!the! construction! and! rehabilitation! of! semi`permanent! and! permanent! structures,! although! many!projects!appeared!to!remain!incomplete!in!August!2011.!

!A!survey!by! the!Education!Cluster!conducted! in!March!2010! found!that!most!parents!wanted! to!send!their!children!back!to!school,!but!86%!of!parents!and!88%!of!youth!said!that!they! lacked!the!financial!means!to!do!so.!As!one!in!five!households!had!lost!a!family!member,!many!others!were!out!of!work,!and!the!majority!had!lost!possessions!during!the!earthquake,!many!no!longer!had!a!source!of!income!to!pay!school! fees!or!replace!ancillary! items! like!textbooks!and!uniforms.!As!a!result,! rather!that!asking! for!a!reduction!in!school!fees,!young!people!and!parents!both!prioritized!employment!and!economic!support!initiatives!to!enable!them!to!re`enroll!children!in!school.1904,1905!More!than!1.5!years!later,!in!November!2011,! a! survey!of! households! in! IDP! camps! revealed! that! 90%!of!parents!whose! children!were!not! in!school!stated!that!prohibitive!cost!was!the!primary!reason!their!children!were!not!enrolled.1906!!The! international! community! has! responded! to! the! impact! of! the! earthquake! by! providing! school!spaces,! distributing! learning!materials,! training! teachers! and! subsidizing! private! school! fees,! including!paying! private! sector! teachers’! salaries! for! at! least! six! months.1907,1908,1909! These! initiatives! remain!











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priorities! during! the! reconstruction! process,! and! the! Haitian! government! plans! to! continue! providing!wage!support!to!many!private!schools!on!a!contractual!basis!into!the!future.1910!!Meanwhile,! population! displacement! has! complicated! the! ability! of! Haitian! children! to! access! school!places!across! the!country.!Due!to!the!movement!of!children!and!their! families!between!Departments,!demand! for! school! places! in! certain! Departments! has! multiplied,! exacerbating! preèxisting! capacity!constraints.! The! Haitian! government! has! identified! this! concern! in! their! Post`Disaster! Needs!Assessment,! prioritizing! the! absorption! of! displaced! pupils! into! the! education! system.1911! However,!according! to!World!Vision,! increased!demand!due! to! student!displacement!may!spur! some!schools! to!increase! the!cost!of!enrollment!and!thus!adversely!affect! the!ability!of!many! families! to!afford!school!placement.!!In! September/October! 2011,! President! Martelly! officially! launched! the! Free! Education! Programme,!which! promised! to! revolutionize! access! to! education! across! Haiti.! The! Programme,! supported! by! a!US$70!million!grant!by!the!World!Bank,!aims!to!provide!free!education!to!142,000!children!aged!6`12!who! have! not! previously! attended! school.! Additionally,! 200,000! children! in! grades! 1! through! 6! from!poor! neighborhoods! will! receive! a! grant! to! cover! education! expenses.1912! The! Programme! is! to! be!supported! by! the! National! Fund! for! Education! (FNE),! established! in!May! 2011,! which! is! funded! by! a!US$0.05!per!minute!surcharge!on! international! calls!and!a!US$1.50!surcharge!on! international!money!transfers.!It!was!estimated!that!the!fund!would!collect!US$8.5!per!month!following!its!implementation!in!June.!However,!after!seven!months!of!operation,!the!Haitian!Senate!Economy!and!Finance!Committee!was! informed! that! the! Fund’s! account! held! only! US$4.8! million! of! the! expected! US$55! million! that!should!have!been!collected!to!that!point,1913!while!the!Minister!of!Education!stated!in!November!2011!that!the!FNE!was!not!operational!because!it! lacked!a! legal!framework.1914!More!recent! information!on!the!operational!status!of! the!FNE!and!the!Free!Education!Programme!were!unavailable!at! the!time!of!writing.! However,! if! operationalized,! it! is! hoped! that! this! initiative,! in! combination! with! school!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1909!Government!of!Haiti,!Haiti&earthquake&PDNA:&Assessment&of&damage,&losses,&general&and&sectoral&needs!(March!2010).!Available!at!http://siteresources.worldbank.org/INTLAC/Resources/PDNA_Haiti`2010_Working_Document_EN.pdf!



1912!Haiti!Education!Cluster,!Education&cluster&information&bulletin:&24&September&2011!(September!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/news/Edu_Cluster_info_bulletin_23_sept_eng.pdf!

1913!J.!Juste,!Haiti:&Digicel&CEO&wants&to&know&where&the&education&money,!Defend.ht!(6!January!2012).!Available!at!http://www.defend.ht/money/articles/business/2398`haiti`digicel`ceo`wants`to`know`whereìs`theèducation`money!

1914!Defend.ht,!“National&fund&for&education&is&not&operational”&says&Haiti&Education&Minister,!Defend.ht!(26!November!2011).!Available!at!http://www.defend.ht/politics/articles/executive/2075`qnational`fund`forèducationìs`notòperationalq`says`haitièducation`minister!

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8.&Education&


construction!and!learning!material!distribution!projects,!will!significantly!improve!young!Haitians’!access!to!education!in!the!future.!

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9.&Labor&and&economic&participation&!Child! labor! may! restrict! children’s! utilization! of! educational! opportunities,! cause! physical! or! mental!injury,! and! facilitate! further! exploitation! and! abuse.1915! Of! paramount! concern! is! the! occupation! and!condition!of!the!working!environment,!the!amount!of!time!dedicated!to!work,!and!the!opportunity!cost!of!employment.!Accordingly,!international!and!Haitian!laws!and!resolutions!do!not!prohibit!all!forms!of!child! labor!but!only!those!considered!to!be!detrimental!to!the!health,!education,!and!wellbeing!of!the!child.1916!!Precisely!what!activities!constitute!“child!labor”!has!been!a!source!of!contention!for!some!time.!Prior!to!2008,! the! international! community! used! a! purely! economic! definition! of! child! labor! that! excluded!domestic!chores!and!household!tasks!that!did!not!provide!direct!economic!benefit,!such!as!child!care!or!tending!livestock,!though!these!tasks!may!have!allowed!others!in!the!household!to!direct!their!energies!toward! paid! employment.1917! International! Labor! Organization! (ILO)! Convention! 138! concerning! the!Minimum! Age! for! Admission! to! Employment! defines! child! labor! (as! opposed! to! work! performed! by!children)!as!work!that!interferes!with!the!child’s!education,!or!threatens!or!causes!harm!to!“the!child’s!mental,!moral,!or!social!development.”1918!For!the!purposes!of!the!Convention,!Haitian!children!are!not!permitted!to!begin!their!working!life!until!they!are!14!years!old!(Haiti!utilizes!the!provision!contained!in!Article! 2,! Paragraph! 4! of! the! Convention,! which! states! that! “…a! Member! whose! economy! and!educational! facilities! are! insufficiently! developed! may,! after! consultation! with! the! organisations! of!employers!and!workers!concerned,!where!such!exist,! initially!specify!a!minimum!age!of!14!years.”).1919!Sommerfelt!has!noted!that!the!definition!contained!in!ILO!Convention!138!relates!to!the!consequences!of! children’s! work,! rather! than! the! activities! performed! themselves.1920! In! contrast,! in! 2008! the! 18th!International! Conference! of! Labour! Statisticians! adopted! a! new! definition! of! child! labor! that!distinguishes! between! household! chores! (“unpaid! household! services”)! and! other! forms! of! work!(“children’s!employment”).1921!The!resolution!defines!child!labor!as:!!






1919!Convention!concerning!Minimum!Age!for!Admission!to!Employment!(C138),!ILO!Convention!C138!(1973).!Available!at!http://www.ilo.org/ilolex/cgi`lex/convde.pl?C138!!




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9.&Labor&and&economic&participation&


• “The!worst!forms!of!child!labour,!including!slavery;!prostitution!and!pornography;!illicit!activities;!and!work!likely!to!harm!children’s!health,!safety!or!morals,!as!defined!in!ILO!Convention!No.!182.!

• Employment!below!the!minimum!age!of!15,!as!established!in!ILO!Convention!No.!138.!• Hazardous!unpaid!household!services,!including!household!chores!performed!for!long!hours,!in!

an!unhealthy!environment,!in!dangerous!locations,!and!involving!unsafe!equipment!or!heavy!loads.”1922!

!The!definitional!separation!of!children’s!employment!and!unpaid!household!services,!in!accordance!with!the!provisions! listed!above,! thus!distinguishes!between!permissible!children’s!work!and!child! labor!on!the!grounds!of!both!the!activities!performed,!and!the!consequences!of!those!activities!on!the!education,!health,!or!development!of!the!child.!!Haiti!has!signed!and!ratified!ILO!Conventions!138!(Minimum!Age!for!Admission!to!Employment)!and!182!(Prohibition!and! Immediate!Action! for! the!Elimination!of! the!Worst!Forms!of!Child!Labour),!as!well!as!the!UN!Convention!on!the!Rights!of! the!Child.!Additionally,!Haiti! is!party!to!a!number!of! international!agreements!prohibiting!slavery,!including!the!Supplementary!Convention!on!the!Abolition!of!Slavery,!the!Slave!Trade,!and!Institutions!and!Practices!Similar!to!Slavery!of!1956,!and!ILO!Convention!29!on!Forced!or! Compulsory! Labour.!Under! these!Conventions,! the! state! has! the! responsibility! to! ensure! that! laws!and!regulations!are!put!in!place!to!realize!and!promote!the!Conventions’!provisions.!!Until!March!2009,!the!Haitian!Labour!Code!authorized!children!to!enter!the!workforce!at!age!15,!except!in! the! case! of! domestic! labor! (age! 12)! and! apprenticeships! (age! 14).1923,1924! In! 2003,! the! Haitian!parliament! adopted! legislation! prohibiting! all! forms! of! abuse,! discrimination,! maltreatment,! or!inhumane!treatment!of!children,!and!criminalized!child!trafficking.!Additionally,!this!legislation!annulled!Chapter!9!of!the!Labour!Code!which!had!permitted!and!governed!children!in!domestic!service.!Following!ratification!of!ILO!Convention!138!in!2009,!the!minimum!age!for!all!work!by!children!was!set!to!14!years,!in!accordance!with!the!Convention.1925,1926!!!Despite! legislation! to! the! contrary,!many! Haitian! children! aged! 7`14! are! engaged! labor.! In! 2005,! the!World! Bank! estimated! that! 33.4%! of! children! in! this! age! group! were! economically! active,! with! boys!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1922!UNICEF,!Progress&for&children&number&8:&A&report&card&on&child&protection!(September!2009).!Available!at!http://www.unicef.org/protection/files/Progress_for_Children`No.8_EN_081309(1).pdf!!

1923!T.!Sommerfelt!and!J.!Pederson,!“Child!Labor!in!Haiti,”!in!H.!D.!Hindman!(ed),!The&world&of&child&labor:&An&historical&and&regional&survey!(New!York:!M.E.!Sharpe,!Inc.,!2009).!




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more! likely! (37.3%)! to! be! economically! active! than! girls! (29.6%).1927! In! terms! of! employment,! it! was!found! that! 22%! of! boys! and! 19%! of! girls! aged! 5`14! were! employed,! for! an! aggregate! estimate! of!approximately!21%.1928,1929!A!review!by!Sommerfelt!found!that!those!aged!7`8!years!worked!an!average!of!two!hours!per!week,!while!those!aged!9`14!worked!nine!hours!per!week.1930!!According!to!the!2007!World!Youth!Report,!the!labor!force!participation!rate!is!higher!for!children!in!the!15`19! age! group.! Among! boys! aged! 15`19! at! the! time! of! the! report,! 51.3%!were! either! employed! or!looking! for! work! in! 2007,! while! the! same! was! true! for! 39.4%! of! girls.! As! such,! the! total! labor! force!participation! rate! for! this! age! group! was! 45.4%,! with! girls! 80%! as! likely! as! boys! to! be! economically!active.1931!According!to!the!Haitian!government,!the!unemployment!rate!for!those!aged!15`19!was!62%,!although! the!percentage! is! considerably! smaller!when! the!age!group! is!expanded! to! include!all! youth!aged!15`24!(35%).1932!!Lack! of! access! to! education! and! poor! socioeconomic! conditions! push!many!Haitian! children! to! begin!their! search! for!work! early.! However,! the! oversaturation! of! available! unskilled! labor! undermines! the!ability! of! both! adults! and! children! to! find! productive! employment.1933! In! rural! areas,! reductions! in!agricultural! output! due! to! environmental! degradation,! the! meager! income! potential! due! to! cheap!imports!of!basic!foodstuffs,!and!the!hardship!of!agricultural!work!generally!have!spurred!many!to!seek!a!livelihood! strategy! elsewhere.1934! The! three! predominant! livelihood! alternatives! are:! 1)! migration! to!urban!areas!within!Haiti,!2)!illegal!migration!to!the!Dominican!Republic,!and!3)!placement!with!another!household!to!work!as!a!servant.!!!Working! children! are! rarely! part! of! Haiti’s! small! formal! labor! sector,! instead! engaging! in! agricultural!work,!petty!commerce,!and!domestic!work.1935!The!U.S.!Department!of!Labor!points!out!that!high!adult!unemployment!in!Haiti!excludes!children!from!work!in!the!industrial!and!commercial!sectors,!resulting!










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in! the!concentration!of! child! labor! in!agriculture!and! informal! industries.1936! In! rural!areas,!agriculture!dominates!children’s!employment—an!uncertain!livelihood!strategy!that!is!often!undertaken!as!part!of!the!“family!enterprise”!rather!than!for!a!salary.1937!Both!boys!and!girls!engage!in!agricultural!activities!in!rural!areas,!while!girls!undertake!more!domestic!work!and!boys!more!trade!and!petty!commerce.!The!employment!profile!of!children!in!urban!areas!is!slightly!different,!with!boys!engaging!in!agriculture!and!trade!while!girls!engage!more!with!petty!commerce!and!domestic!work.! It!should!be!noted!that!most!work! carried!out!by! children! relates! to! their! family’s! livelihood! strategy!and! is! therefore!unpaid.!Only!13%!of!employed!children!earned!a!wage!in!2001,!while!roughly!one!third!were!self`employed!and!54%!worked!for!the!family!enterprise.1938!!!

A.&Children&in&domestic&service&and&servitude&!Children!working!as!domestic!servants!are!among!Haiti’s!most!vulnerable!populations,!as!most!of!their!time! is!spent!within!the!closed!household!environment!with! less!access!to!external!contact!than!most!other! children.! The!hidden!nature!of! child! domestic! servants’! lives! complicates! both! the! study!of! the!realization!of!their!rights,!as!well!as!the!design!and!implementation!of!policies!and!programs!promoting!their! protection.1939! However,! available! data! suggest! that! these! children! confront! significant! risks! to!their! protection,! development,! and! rights! fulfillment,! necessitating! effective! interventions! that! both!assist! those!children! living! in!domestic! service!and!servitude,!and!reduce! the!vulnerabilities! that!drive!children!and!families!to!resort!to!child!domestic!service!to!meet!basic!needs.!!!This! analysis! draws! information! predominantly! from! three! seminal! studies! of! Haitian! child! domestic!servants,1940,1941,1942!with!supplemental!information!derived!from!secondary!sources.!Unfortunately,!this!Report!did!not!find!any!nationally!or!sub`nationally!representative!data!collected!since!the!January!2010!earthquake.! As! such,! it! is! unclear! what! impact! the! earthquake! had! on! the! phenomenon! of! child!domestic!service! in!Haiti,! though! it! is! likely!that!the!devastation!wrought!by!the!earthquake! increased!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1936!U.S.!Department!of!Labor,!Haiti,!Bureau!of!International!Labor!Affairs!(2011).!Available!at!http://www.dol.gov/ilab/media/reports/iclp/Advancing1/html/haiti.htm!!



1939!G.!R.!Smucker,!Y.!F.!Pierre,!and!J.!F.!Tardieu,!Lost&childhoods&in&Haiti:&Quantifying&child&trafficking,&restavèks,&&&victims&of&violence,!Pan!American!Development!Foundation!Protecting!Human!Rights!Project!(November!2009).!Available!at!http://www.crin.org/docs/Haiti_lost_childhoods.pdf!





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children’s! risk! of! both! placement! as! a! domestic! worker! and! adverse! outcomes! as! a! result! of! their!placement.!!!!

i..Types.and.definitions.of.child.domestic.service.in.Haiti.!Despite! the! existence! of! national! and! international! regulations! limiting! the! acceptable! terms! of! child!labor,! generally,! and! child! domestic! labor,! specifically,! the! use! of! children! as! domestic! servants! is!widespread!in!Haiti.1943!However,!children’s!experiences!as!domestic!servants!fall!along!a!continuum!of!rights! fulfillment:! On! the! one! hand,! some! children!working! as! domestic! servants! enjoy! opportunities!that! are! equal! to! or! greater! than! other! children! of! similar! backgrounds.! On! the! other! hand,! many!children! are! exploited,! with! lasting! negative! impacts! on! their! health,! wellbeing,! protection,! and!development.1944,1945!Before!examining!the!key!characteristics!of!various!domestic!service!arrangements,!it! is! first! necessary! to! explore! the! Haitian! cultural! understanding! of! terms! relevant! to! child! domestic!service.!!Children!are!commonly!referred!to!as!either!pitit!or!timoun!in!Haitian!Creole.!In!general,!pitit!is!used!to!describe!a!biological!child,!such!as!for!“Jean’s!child”!(petit&Jean).!In!contrast,!timoun!is!used!to!describe!children!more!generally.1946!The!term!“restavek”!(from!the!French!“rester&avec,”!or!“living!with”)!is!used!internationally!to!denote!a!child!domestic!worker.!Although!this!Report!uses!this!term!for!the!purpose!of!clarity!and!consistency!with!cited!data,!it!is!important!to!note!that!the!term!is!considered!pejorative!in!Haiti! and! carries! significant! negative! connotations,! including! that! such! children! are! dependent! and!servile!because!they!are!living!with!a!stranger!and!lack!any!family!ties.!Additionally,!the!term!may!also!be!used!to!highlight!a!child’s!plight!and!underprivileged!situation.1947,1948!Additionally,! it! implies!a!long`

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1943!U.S.!Department!of!Labor,!Haiti,!Bureau!of!International!Labor!Affairs!(2011).!Available!at!http://www.dol.gov/ilab/media/reports/iclp/Advancing1/html/haiti.htm!!


relocation&and&work,!FAFO!(May!2002).!Available!at!http://www.fafo.no/ais/other/haiti/childlabour/EEDH_Report_draft_english.pdf!






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term! contract! whereby! the! “receiving”! household! has! assumed! responsibility! for! raising! the! child! in!return!for!the!child’s!labor,!and!that!the!child!does!not!receive!payment!for!this!labor.1949!!!Various!studies!have!noted!that!survey!respondents!are!increasingly!reticent!to!report!restaveks!in!their!household,!given!the!pejorative!connotations!of!the!term,!legal!restrictions,!and!their!general!belief!that!they!have!not!exploited!these!children!but!merely!“provided!assistance.”1950!Instead,!as!Sommerfelt!has!observed,!survey!respondents!may!be!more!likely!to!report!these!children!as!“timoun&ki&rete&kay&moun”!(“children!who!live!with!others”)!and!“timoun&ran&sevis”!(“children!who!render!services”).1951!Due!to!the!stigma!surrounding!the!term!“restavek,”!and!to!reduce!possible!biases!in!reporting!the!presence!of!child!domestic!servants!generally,!many!household!surveys!relating!to!child!domestic!labor!do!not!directly!ask!whether!any!children!in!the!household!fall!into!the!aforementioned!categories.!Instead,!or!additionally,!these! surveys! assess! risk! factors! associated! with! child! domestic! servants’! experiences! and! cross`correlate! these! risk! factors! to! derive! estimates! of! the! numbers! of! children! in! each! category.! Three!indicators!are!generally!used:!1)! the!child! is!not! living!with!at! least!one!biological!parent,!2)! the!child!bears!a!high!workload,!and!3)!the!child!is!differentially!treated!with!respect!to!education.1952,1953,1954!!!While! these! indicators! may! yield! more! honest! reporting! of! the! situation! of! children! in! Haitian!households,!the!approach!suffers!two!primary!shortcomings.!Principally,!classifying!children!as!domestic!servants!or!restaveks!based!on!workload!and!education!means!that!it!is!not!possible!to!state!that!child!domestic!servants!are!worse!off!than!other!children!in!these!areas,!as!they!have!been!classified!due!to!these!characteristics.!Secondly,!as!there!is!no!accepted,!standardized!definition!for!“restavek”!and!other!relevant!categories,!the!diversity!of!measurement,!cross`correlation,!and!classification!strategies!used!in!different!studies!will! inherently!produce!disparate!estimates.1955,1956,1957!For!example,! is!the!decision!to!












!


classify!a!child!as!a!restavek!or!other!category!informed!by!whether!that!child!is!remunerated!for!their!work?!Does!sending!the!child!to!school!constitute!sufficient!remuneration?! Is! it! important!whether!or!not! the!child’s! labor!was! the!primary! reason! for!placement! in! the!“receiving”!household?!Sommerfelt!has! noted! that! both! the! decision! to! include! or! exclude! such! variables,! and! the! threshold! values!indicating!differential!treatment,!profoundly!influence!estimates!of!the!prevalence!of!different!forms!of!child!domestic! labor;! including!the!criteria!that!only!those!children!who!are!not!remunerated!for!their!work!can!be!considered!“restaveks”!would!yield!estimates!that!capture!only!a!portion!of!all!Haitian!child!domestic! servants.1958!However,! international!definitions!of! child! labor!do!not! include! the!question!of!whether!children’s!work!is!remunerated.!As!a!result,!though!the!term!“restavek”!is!generally!understood!in!Haiti!to!entail!unpaid!work,!the!lack!of!conceptual!specificity!as!to!whether!remuneration!may!come!through! goods,! services,! or! the! provision! of! education! or! other! opportunities,! and! other! definitional!discrepancies,!significantly!compromise!the!accuracy!and!comparability!of!prevalence!estimates.!!Smucker,!Pierre,!and!Tardieu’s!2007/08!study!in!troubled!urban!neighborhoods!of!Port`au`Prince,!Cap`Haitiën,! Gonaïves,! Saint`Marc,! and! Petit`Goâve! found! that! a! large! number! of! child! boarders! in! these!neighborhoods!performed!a!workload!to!similar!to!children!classified!as!restaveks,!and!concluded!that!“kinship! ties! and! boarding! arrangements! may! serve! to! camouflage! restavèk! treatment! that! extends!beyond!the!children!labeled!as!restavèk&children.”1959!Despite!the!fact!that!children!in!Haiti!are!generally!expected! to!perform! some! level! of! household!work,1960,1961! Smucker!et&al.&determined! that! the!heavy!workload!assigned!to!these!children!necessitated!the!inclusion!of!a!child!placement!category!reflecting!their! significant! labor! responsibilities,! despite! the! fact! that! these! children,! by!definition,! did!not! have!less!access!to!education!than!other!children!in!the!receiving!household.!Smucker!et&al.! identified!three!general! categories! of! children:! Restaveks,! boarders,! and! restavek5boarders,! where! restavek`boarders!were!defined!as!those!children!who!were!attending!school,!as!per!the!placement!arrangement!between!the!sending!and!receiving!households,!but!who!were!also!performing!a!heavy!workload!similar!to!that!of!restavek&children.!The!study!revealed!that,! in!contrast!to!popular!perception,!the!majority!of!boarders!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1957!T.!Sommerfelt,!Child&domestic&labour&in&Haiti:&Characteristics,&contexts&and&organisation&of&children’s&residence,&



relocation&and&work,!FAFO!(May!2002).!Available!at!http://www.fafo.no/ais/other/haiti/childlabour/EEDH_Report_draft_english.pdf!





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performed! a! heavy! workload! similar! to! that! of! restavek! children,! but! were! generally! not! labeled! as!restaveks.1962!!It! is! also! important! to! note! that! definitions! and!measures! of! the! prevalence! of! children! in! domestic!servitude! consider!only! that! the! child! is!not! living!with!either!biological! parent,! rather! than!excluding!those! living! with! other! family! members.! Consolidating! kinship! ties! is! one! factor! contributing! to! the!placement!of! children! in!other!households.! Similarly,!wealthier!households!within!an!extended! family!network!may!be!pressured!to!accept!children!by!both!close!and!distant!relatives,!even!if!the!receiving!household!is!only!marginally!better!off.!Refusal!to!take!the!child!may!result!in!criticism,!due!to!the!belief!that! the! child’s! placement! will! result! in! an! education! and! social! mobility! in! exchange! for! the! child’s!work.1963!As!a!result,!familial!networks!are!the!primary!route!for!placing!child!domestic!servants!in!Haiti.!!The!overwhelming!majority!of!child!domestic!servants!in!Haiti!are!related!in!some!way!to!a!member!of!the!receiving!household,!though!this!trend!is!changing!over!time.!In!2002,!Sommerfelt!found!that!85.8%!of!child!domestic!workers!lived!in!a!household!with!either!their!sibling,!a!grandparent,!an!uncle!or!aunt,!an! adopted! relation,! or! another! relative,! though! significant! differences! were! observed! by! both! the!child’s!gender!and!urban/rural!status! (Figure!133).!Boys!were!more! likely! than!girls! to!be! living!with!a!sibling!or!grandparent!in!both!urban!and!rural!areas,!while!girls!were!more!likely!to!be!living!with!either!an!uncle!or!aunt,!other!relative,!or!non`relation.!Sommerfelt!has!noted!that!boys!were!more!likely!to!be!living!with!a!close!relative,!including!siblings,!grandparents,!or!an!aunt!or!uncle!(67%!of!urban!boys!and!75%!of! rural!boys)! than!girls! (37%!urban!girls! and!68%!of! rural! girls).!Urban!girls!were!up! to! twice!as!likely! to! be! living! with! a! non`relative! (32%)! than! children! in! any! other! gender! and! urban/rural!category.1964!!





!


Figure.133:.CoTresidents.of.child.domestic.workers,.by.sex.and.urban/rural.status,.2002.



!!The!2007`08!study!by!Smucker,!Pierre,!and!Tardieu! found! that!22%!of!child!domestic!workers!had!no!familial! tie!to!the!head!of!the!household,1965!compared!to!14.2%!found!by!Sommerfelt! in!2002!(Figure!134).1966!However,!as!survey!respondents!were!drawn!only!from!urban!areas,!Smucker!et&al.’s!estimates!approximate! the! average!of! those! found! for! urban!male! and! female! child! domestic! servants! in! 2002.!Additionally,! Smucker!et&al.! present! results! for! restaveks! specifically! rather! than! for!all! child!domestic!workers,! though! review! of! the! studies’! survey! methods! indicate! that! they! may! refer! to! the! same!population,!and!are!therefore!comparable.!Smucker!et&al.’s!study!also!noted!a!recent!trend!towards!the!placement! of! children!with! strangers,! rather! than! family,! supporting! findings! from! other! studies! that!child!placement!increasingly!occurs!through!the!use!of!middlemen,!as!will!be!discussed!in!greater!depth!below.1967!!!!





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Figure.134:.Restavek.kin.ties.to.household.heads.(%),.2008.

. Frequency. %.Nephew/niece! 366! 54!God!son!or!daughter! 17! 3!Other!relative! 146! 21!None! 151! 22!Total! 680! 100!


!!Though! familial! ties! are! seen! as! very! important! in! Haitian! culture,! ties! to! the! head! of! the! receiving!household!do!not!preclude!mistreatment,!and!even!child!domestic!workers!with!ties!to!the!family!they!serve!remain!vulnerable.1968!According!to!Sommerfelt,!similar!treatment!of!related!and!unrelated!child!domestic! workers! indicates! the! independence! of! notions! of! family! and! work,! especially! given! the!observation!that!biological!children!of!the!head!of!household!are!also!expected!to!contribute!significant!amounts!of!labor!to!the!household!enterprise.1969!Nevertheless,!available!evidence!suggests!that!familial!ties!between!the!child!domestic!worker!and!household!head!offer!at! least!some!degree!of!protection,!and!children!with!no!kinship!ties!face!a!greater!risk!of!abuse.1970,1971!!At! one! end! of! the! spectrum! of! the! wide! continuum! characterizing! the! types! and! dynamics! of! child!placement!are!arrangements!of!paid!board,!in!which!a!family!pays!for!a!child!to!live!and!eat!in!the!home!of!another!family;!on!the!other,!arrangements!of!board`for`child`work,!in!which!a!child’s!compensation!for!working! in!another’s! family’s!home!consists!of!board!alone.1972,1973,1974,1975! Education!and! labor!are!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1968!G.!R.!Smucker!and!G.!F.!Murray,!The&uses&of&children:&A&study&of&trafficking&in&Haitian&children,!USAID/Haiti!Mission!(December!2004).!Available!at!http://pdf.usaid.gov/pdf_docs/PNADF061.pdf!









1974!G.!R.!Smucker!and!G.!F.!Murray,!The&uses&of&children:&A&study&of&trafficking&in&Haitian&children,!USAID/Haiti!Mission!(December!2004).!Available!at!http://pdf.usaid.gov/pdf_docs/PNADF061.pdf!

!


generally!used!to!classify!and!characterize!these!arrangements.!As!a!result,!three!general!categories!of!child! placements! emerge:! 1)! the! child! placed! in! another! family’s! home! does! not! work! but! attends!school,!2)!the!child!both!works!and!attends!school,!and!3)!the!child!works!but!does!not!attend!school.!This! Report! uses! the! term! “boarders”! to! refer! to! children! in! the! first! category,! and! the! term! “child!domestic!worker”!to!refer!to!children!in!either!the!second!or!the!third!category.!It!should!be!noted!that!“restaveks”!may!be!in!either!the!second!or!third!category,!as!the!operational!definition!discussed!above!does! not! exclude! the! possibility! that! restavek! children! may! attend! school,! only! that! they! are!differentially!treated!with!regard!to!education.!!Two! additional! and! interrelated! dynamics! are! required! to! characterize! child! placement! arrangements!and!the!risks!faced!by!these!children.!The!first!of!these!concerns!the!factors!motivating!the!placement!of!the! child.! According! to! Sommerfelt,! child! placement! arrangements! at! each! end! of! the! spectrum! are!uniplex!in!that!“the!relationship!between!the!child!and!the!present!caretaker!is!defined!in!terms!of!one!function;! in! the! first!case! the! function!of!board,! in! the!second!of!work.”1976! In!contrast,!arrangements!falling!between! these!end!points!are!multiplex,! as! children!will! be!expected! to!work! to! some!degree,!may!or!may!not!receive!access!to!education,!and!the!role!of!the!new!caretaker!may!include!aspects!of!parental!responsibilities,!such!as!care,!upbringing,!and!discipline.1977!!!The! factors!motivating! a! child’s! placement! and! the! sending! household’s! access! to! resources! are! key!determinants!of!the!dynamics!of!the!child’s!placement!arrangement.!When!the!decision!to!place!a!child!in!a! receiving!household! is!motivated! solely!by!providing! that! child!with!access! to!education,!and! the!sending!household!has!the!ability!to!pay!for!the!child’s!upkeep!and!school!costs,!the!child!is!considered!a!boarder!by!the!receiving!household!and!the!community,!rather!than!as!a!child!domestic.!On!the!other!hand,!many!children!are!placed! in!a! receiving!household!because! their!parents!are!unable! to!care! for!them! and! provide! for! their! basic! needs.! In! such! cases,! the! child’s! placement! is! motivated! by! the!understanding!that!the!child’s!basic!needs!will!be!met!in!exchange!for!the!child’s!labor!in!the!household,!in! which! case! the! child! is! categorized! as! a! domestic! servant.1978,1979,1980! The! factors! motivating! child!placement! are! discussed! in! further! detail! below.! However,! it! is! important! to! note! that! in! practice,!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1975!T.!Sommerfelt!and!J.!Pederson,!“Child!Labor!in!Haiti,”!in!H.!D.!Hindman!(ed),!The&world&of&child&labor:&An&historical&and&regional&survey!(New!York:!M.E.!Sharpe,!Inc.,!2009).!









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children!can!very!rarely!be!considered!pure!“boarders,”!as!all!children!in!Haiti!are!generally!expected!to!contribute! to! household! chores,! and! it! is! often! not! possible! to! ascertain! the! primary! or! relative!importance! of!motivations! for! the! child’s! placement.1981,1982! As! a! result,! the! vast!majority! of! children!placed! in! receiving! households! are! probably! expected! to!work! to! varying! degrees,! even! those!whose!placement!was!motivated!by!providing!the!child!with!access!to!education,!while!the!probability!that!a!placed!child!will!be!enrolled!in!school!depends!on!both!the!sending!family’s!ability!to!pay!for!the!child’s!upkeep!and!education!costs!and!the! formality!of! the!arrangement!between!the!sending!and!receiving!households.!!An!important!final!dimension!in!characterizing!and!categorizing!children’s!placement!involves!the!terms!and! formality! of! the! arrangement! between! sending! and! receiving! households.! On! one! extreme,! the!expectation!that!the!boarding!child!will!attend!school!is!explicitly!stated!as!a!condition!of!the!placement;!on!the!other!extreme,!the!family!placing!its!child!into!domestic!service!only!hopes!that!the!child!will!be!provided!with! an! education.1983! The! terms! and! formality! of! child! placement! arrangements! are! largely!determined!by!the!economic!situation!of!the!sending!household,!and!both!are!also!important!indicators!in!determining!children’s!probability!of!attending!school,!realizing!their!rights,!and!the!risk!of!abuse!and!neglect.!When!children!are!placed!solely!for!the!purpose!of!education,!and!the!sending!family!has!the!ability! to!pay! for! the!child’s!upkeep!and!schooling,! the!boarding!agreement!often!explicitly! states! the!terms!of! the!arrangement!and!expectations!of!each!household!and! the! child! itself.! In! such! cases,! the!parties!will!agree!on!which!school!the!student!is!to!attend,!the!amount!of!money!paid!to!the!receiving!household! for!upkeep!and!expenses,!etc.!At! the!other!end!of! the!spectrum,!when!children!are!placed!because! their! parents! cannot! support! them,! the! terms! of! the! agreement! are! informal! and! rarely!discussed.!According!to!Sommerfelt,!in!these!latter!agreements!“parents!conveyed!the!impression!that!they!were! in! no! position! to! pose! any! demands! regarding! how! their! children!were! to! be! treated,! but!should! rather! express! gratitude! to! the! new! guardians! for! supporting! their! child.”1984! In! fact,! several!respondents! in! Sommerfelt’s! 2002! study! who! had! placed! their! child! in! another! household! due! to!poverty! stated! that! they! did! not! know! where! the! child’s! host! household! was! located.! Again,! the!overwhelming!majority!of!child!placement!agreements!fall!between!these!two!extremes.!!!Figure!135!presents!a!matrix!of! child!placement!agreement!categories,! incorporating! the!determinant!attributes! of! workload,! school! attendance,! and! the! formalization! of! the! terms! of! the! placement!agreement.!The!matrix! is! illustrative,! rather! than!definitive,!due! to! the! lack!of!accepted,! standardized!definitions! of! each! term! and! cutoffs! for! workload! categories.! The! previously! discussed! operational!







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definitions!highlight!the!fact!that!restaveks! (and,!by!extension,!restavek5boarders)!by!definition!have!a!heavy! workload,! but! it! is! important! to! note! that! only! children! those! with! a! heavy! workload! whose!education!was!a!formal!condition!of!the!placement!may!be!considered!restavek5boarders.!Those!with!a!heavy!workload!but!whose!education!was!not!a!condition!of!the!placement!may!be!either!restaveks!or!child! domestic! servants,! depending!on!which!definition! is! used! and!whether! the! child! is! differentially!treated! regarding! access! to! education.! Those! children! whose! education! was! a! condition! of! their!placement! and!who! are! responsible! for! either! no! or! some!work! in! the! household! are! categorized! as!boarders,!as!education!may!be!deemed!to!be!the!primary!placement!motivation,!and!because!they!do!not!fulfill!the!definitional!requirement!of!having!a!heavy!workload.!Children!whose!placement!was!not!conditional!on!their!enrollment! in!school,!but!who!are!required!to!contribute!a!degree!of! labor!to!the!household,!are!categorized!in!the!table!as!child!domestic!workers.!However,!this!categorization!depends!on!definitional!interpretation,!the!relative!importance!of!education!and!the!provision!of!board!for!labor,!and! threshold! values! for! workload! categories.! As! such,! the! matrix! presents! one! of! many! possible!interpretations! of! categories! of! child! placement! arrangements,! but! is! a! useful! tool! to! represent! their!diverse!characteristics.!!Figure.135:.Matrix.of.categories.and.characteristics.of.child.placement.arrangements.

. Attends.school.

Workload.

.Yes,.as.formal.condition.of.placement.

Yes,.but.not.as.formal.condition.of.

placement.No.

Heavy. Restavek`boarder!Restavek/!

Child!domestic!servant!

Restavek/!Child!domestic!

servant!

Some. Boarder! Child!domestic!servant!

Child!domestic!servant!

None. Boarder! N/A! N/A!

!!Finally,!it!is!also!important!to!note!that!the!lived!experiences!of!children!in!each!of!these!classifications!can! vary! greatly.! A! child!who! is! expected! to!work! heavily! but! does! not! attend! school! has! a! different!experience!of!rights!realization!than!a!child!with!a!heavy!workload!who!does!attend!school,!or!a!child!who!attends!school!and!does!not!work,!but!is!the!victim!of!physical,!psychosocial,!or!sexual!abuse!within!the!host!household.!As!human!rights!are!indivisible!(i.e.,!they!cannot!be!traded!off,!and!one!cannot!have!greater!“value”!than!any!other),! it! is!not!necessarily!possible!from!a!human!rights!perspective!to!state!that!the!child!without!access!to!education!is!worse!off!than!the!child!without!access!to!bodily!integrity,!or! vice& versa—only! that! each! of! the! children! is! deprived! of! rights,! and! that! the! characteristics! of!

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deprivation! differ! between! them.! As! a! result,! children’s! realization! of! their! rights! occurs! along!continuums!both!between!and!within!categories!of!child!placement!arrangements!in!Haiti.1985!!!!

ii..Prevalence.and.demographic.characteristics.of.children.in.domestic.service.!It! has! been! noted! that! it! is! impossible! to! derive! “correct”! or! “accurate”! estimates! of! child! domestic!service! in!Haiti,! as! these! estimates! necessarily! depend!on! the! definitions! and! indicators! used! in! each!assessment.1986! Discrepancies! and! overlaps! between! definitions! of! child! domestic! workers,! restaveks,!and!restavek5boarders!have!led!to!a!very!wide!range!of!estimates!of!both!the!number!and!percentage!of!Haitian!children!in!each!category.!In!addition!to!definitional!discrepancies,!stigma!surrounding!the!term!“restavek,”!and,!as!a! result,! survey!respondents’!unwillingness! to!report! the!presence!of!a!restavek! in!their! household,! further! complicates! efforts! to! examine! the! extent! of! the! phenomenon.1987,1988! The!longstanding! tradition! of! placing! children! in! a! different! household! for! reasons! other! than! domestic!service! introduces!additional!complexity,1989!as!does!the!fact!that!sources!vary!on!both!the!number!of!children!in!Haiti!and!their!share!of!the!total!Haitian!population.1990!For!these!reasons,!estimates!of!the!number!of!child!domestic!workers,!restaveks,!and! restavek5boarders!and! their! share!of! the! total! child!and!Haitian!population!must!be!interpreted!with!caution.!Despite!significant!differences!between!these!estimates,! however,! it! is! clear! that! child! domestic! service! and! servitude! is! prevalent! in! Haiti,! and! of!pressing!concern!to!actors!seeking!to!protect!and!promote!children’s!rights!and!support!their!physical!and!psychosocial!development!and!wellbeing.!!!In!2002,!Sommerfelt’s!study!of!child!domestic! labor!estimated!that!there!were!approximately!173,000!child!domestic!servants!in!Haiti,!accounting!for!8.2%!of!all!children!aged!five!to!17.!The!analysis!defined!child! domestic! labor! according! to! parent`child! separation! (living! with! neither! biological! parent),! high!child!workload! (children! in! the! three!highest! age`specific!workload!quintiles),! and! lack!of!or!delays! in!










!


education!(not!enrolled,!or!not!at!the!correct!stage!for!the!child’s!age).!Sommerfelt!notes!that!restricting!the! definition! to! include! only! those! children! whose! workload! falls! in! the! two! highest! age`specific!workload!quintiles!would!result! in!an!estimate!of!124,000!child!domestic!servants,!comprising!5.9%!of!the!total!population!aged!five!to!17.!To!highlight!the!potential!impact!of!underreporting!due!to!stigma,!Sommerfelt!states!that!only!32,000!children!(1.4%)!were!reported!as!restaveks!when!questioned!directly!using!that!term,!while!mothers!reported!around!12,000!children!doing!housework!in!other!households,!and!85,000!children!as!being!“adopted”!by!other!households.1991!An!internal!document!of!the!UN!Office!for! the! Coordination! of! Humanitarian! Affairs! (UN! OCHA)! Haiti! Office! describing! the! humanitarian!situation! in! Haiti! on! the! eve! of! the! 2010! earthquake! cites! Sommerfelt’s! estimate! of! 173,000! child!domestic! servants,1992! indicating! its!acceptance!as!a! reliable!operational!estimate.! In!contrast,! in!2007!the! Pan! American! Health! Organization! (PAHO)! cited! estimates! indicating! that! up! to! 300,000! children!were!living!as!restaveks.1993!!The!U.S.!Department!of!State!noted!in!2009!that!estimates!of!the!number!of!restavek!children!in!Haiti!ranged! between! 90,000! and! 300,000,! while! an! additional! 3,000! were! believed! to! reside! in! the!Dominican!Republic.1994!However,!by!2011,!the!Department!of!State!had!revised!and!narrowed!its!range!of!estimates! to!between!173,000!and!225,000! restaveks! living! in!Haiti.1995!The!2009!UN!Report!of! the!Special! Rapporteur! on! contemporary! forms! of! slavery,! including! its! causes! and! consequences! cited! a!wider! range!of!estimates!of! restavek! children,!between!150,000!and!500,000.!The!Special!Rapporteur!stated!that!the!number!of!restavek!children!was!likely!to!have!increased!over!the!preceding!years!due!to!nationwide!economic!deterioration,!though!no!new!studies!estimating!the!number!of!restavek!children!had!been!released!prior!to!the!drafting!of!her!report.1996!!Two!months!after!the!release!of!the!Special!Rapporteur’s!report,!Smucker,!Pierre,!and!Tardieu!published!an! analysis! of! data! collected! during! December! 2007,! January! 2008,! and! December! 2008! in! troubled!urban!neighborhoods!in!Port`au`Prince,!Cap`Haitiën,!Gonaïves,!Saint`Marc,!and!Petit`Goâve.!Their!study!found!that!16%!of!the!3,188!children!surveyed!could!be!classified!as!restaveks,!while!an!additional!6%!could!be!classified!as!restavek5boarders.!As!such,!Smucker!et&al.!estimated!that!by!2008,!22%!of!children!in! the! five! cities! surveyed! were! treated! as! restaveks,! with! significant! differences! observed! between!surveyed! cities! (Figure! 136).! Their! extrapolation! of! this! prevalence! estimate! based! on! 2010! census!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1991!T.!Sommerfelt,!Child&domestic&labour&in&Haiti:&Characteristics,&contexts&and&organisation&of&children’s&residence,&




1994!U.S.!Department!of!State,!Trafficking&in&persons&report&2009,!Office!to!Monitor!and!Combat!Trafficking!in!Persons!(June!2009).!Available!at!http://www.state.gov/documents/organization/123357.pdf!

1995!U.S.!Department!of!State,!Trafficking&in&persons&report&2011,!Office!to!Monitor!and!Combat!Trafficking!in!Persons!(June!2011).!Available!at!http://www.state.gov/g/tip/rls/tiprpt/2011/index.htm!!


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projections!suggested!that!approximately!225,000!children!were!treated!as!restaveks!on!the!eve!of!the!January! 2010! earthquake! in! urban! areas! alone.1997!However,! it! should! be! noted! that! Smucker!et& al.’s!prevalence! estimate! was! derived! from! data! collected! only! in! “troubled! neighborhoods”! of! the! five!surveyed! cities.! Available! data! suggest! that! households! in! such! neighborhoods! are! of! lower!socioeconomic! status,! and! that! wealthier! households! are! more! likely! to! contain! restavek! children!(discussed!further,!below).!Additionally,!Smucker!et&al.’s!estimate!does!not!include!restavek&or!restavek`boarder!children!in!rural!areas.!Both!of!these!topics!are!also!described!in!further!detail,!below;!however,!it!is!important!to!note!here!that!these!two!factors!mean!that!the!estimate!of!225,000!children!living!in!restavek`like! situations! is! likely! an! underestimate! of! the! number! of! children! living! in! such! situations!across!Haiti!(using!Smucker’s!definition!of!categories!of!child!placement).!!Figure.136:.Percentage.of.children.experiencing.treatment.as.restaveks.in.five.Haitian.cities,.2008.

.Sites.of.study. %. N.

.PortTauTPrince. 28. 1669.!

Carrefour!Feuilles!/!Fontamara!/!Martissant! 26! 300!! Solino!/!Bel`Air! 27! 482!! Cité!Soleil! 44! 257!! Delmas!/!Tabarre! 22! 292!! Mon!Repos!/Lamentin! 23! 298!

.Cap.Haitian. 14. 590.! Bassin!Rodo! 13! 194!! Centre!Ville! 16! 229!! Petite!Anse! 14! 167!

Gonaïves. 11. 416.StTMarc. 18. 317.PtTGoâve. 20. 236.Total. 22. 3188.


!!Despite! these! limitations,! Smucker,! Pierre,! and! Tardieu’s! estimate!of! 225,000! restaveks! and! restavek5boarders! in! urban! areas,! 1998! ceteris& paribus,! supports! the! assertion! of! the!UN! Special! Rapporteur! on!contemporary! forms! of! slavery,! including! its! causes! and! consequences,! that! the! number! of! restavek!



!


children!in!Haiti!increased!significantly1999!in!the!years!between!this!2008!study!and!Sommerfelt’s!2002!study!(which!estimated!173,000!children!in!domestic!service2000).!Concomitant!increases!were!observed!over! the! period! in! the! proportion! of! households! estimated! to! contain! child! domestic! workers! or!restaveks! and! restavek5boarders.! In! 2002,! Sommerfelt! estimated! that! 9%! of! all! Haitian! households!contained!at!least!one!child!domestic!servant,!and!that!the!probability!of!a!household!containing!a!child!domestic! worker! increased! with! household! wealth! (Figure! 137).2001! By! 2008,! Smucker,! Pierre,! and!Tardieu! found! that! 30%!of! surveyed!households! contained! at! least! one! restavek! or! restavek5boarder,!with!prevalence!estimates!in!surveyed!sites!ranging!between!9%!and!46%.2002!While!it!is!important,!once!again,! to! consider! that! the!operational!definitions!used! to! classify! a! child! as! a! child!domestic!worker,!restavek,!or!restavek5boarder!may!have!differed,!reducing!the!comparability!of!estimates,!the!findings!lend!support!to!the!suggestion!that!the!number!of!children!placed!in!domestic!service!and!their!share!of!the!total!child!population!has!increased!over!the!last!decade.!!!Figure.137:.Percentage.of.households.with.one.or.more.child.domestic.workers,.2002.



!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1999!UN!GA,!Report!of!the!special!rapporteur!on!contemporary!forms!of!slavery,!including!its!causes!and!consequences,!Gulnara!Shahinian,!UN!Doc.!A/HRC/12/21/Add.1!(2009).!Available!at!http://www.unhcr.org/refworld/docid/4ac0c6b42.html!






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Figure.138:.Percentage.of.households.with.restavek.children,.by.survey.site,.2008.


!!Child!domestic!servants!in!Haiti!are!generally!older!than!other!children!in!receiving!households,!and!the!proportion!of!children!who!are!domestic!servants!in!each!age!category!is!different!than!that!for!children!who!are!not!domestic!servants.!In!2008,!the!average!age!of!restaveks!and!restavek5borders!was!found!to!be!12.3,!approximately!eight!months!older!than!the!average!age!of!other!children!(11.6!years)! (Figure!139).2003!This!age!discrepancy!is!due!the!fact!that!many!children!become!domestic!workers!around!age!12!(!Figure!140).!As!such,!the!largest!proportion!of!all!child!domestic!workers!is!between!ages!12!and!17.!The!reason/s! for! this!differential! age!distribution! is!unclear,!but! Sommerfelt!has! suggested! that! it!may!be!due! to!children’s! search! for!work!after!completing! the!sixth!year!of! school,!and/or! the! fact! that!older!children!are!more!able!to!perform!household!work!than!their!younger!peers.2004!In!2002,!an!estimated!134,000!of!the!total!estimated!173,000!child!domestic!workers!were!under!15!(77.5%!of!child!domestic!workers,! or! 7.7%! of! the! total! child! population! aged! 5`14),! and! 115,000! child! domestic!workers!were!under!14!(66.5%!of!child!domestic!workers,!or!7.3%!of!the!total!child!population!aged!5`14).2005!!






27

Figure 2 illustrates that in the larger cities (Port-au-

Prince and Cap-Haïtien) there is little difference in

the average age of restavèk versus other children.

On� the� other� hand,� in� Gonaïves,� Saint� Marc� and�

Petit-Gôave,� age� differences� are� more� noticeable.�

Servant� children� by� household� and� location.

Overall, 30% of survey households have restavèk

servant� children� present;� however,� the� Carrefour�

Feuilles/Fontamara/Martissant survey site has by far

the� highest� proportion� of� households� with� restavèk�

children� (46%),� and� Cap-Haïtien� the� lowest� (21%).�

Other� sites� with� a� high� proportion� of� households�

with� restavèk� servant� children� include� Solino/Belair�

(35%) and Delmas/Tabarre (37%).

Some survey households have more than one

restavèk child servant, although this is a relatively

small minority of households (see Table 11). For

example, 38% of households in Carrefour Feuilles/

Fontamara/Martissant� have� a� restavèk� servant� child;�

however,� another� 9%� of� households� at� this� site� have�

at� least� two� restavèk� children,� and� 9%� of� Delmas/

Tabarre� households� also� have� at� least� two� restavèk�

servant children present.

!


Figure.139:.Average.age.of.restaveks.and.restavekTboarders.compared.to.other.children,.2008.

Status! Average.age.! Number.of.children.surveyed!Restavèk&children! 12.3! 684!Other!children! 11.6! 2,504!Total! 11.7! 3,188!


!!Figure.140:.Age.distribution.of.child.domestic.workers.and.other.children.(%),.by.sex,.2002.

!*!Grey!lines!are!child!domestic!workers,!black!lines!are!other!children.!Source:!T.!Sommerfelt,!Child&domestic&labour&in&Haiti:&Characteristics,&contexts&and&organisation&of&children’s&


!!An! important! aspect! of! child! domestic! service! and! servitude! in! Haiti! is! that! girls! comprise! a! greater!proportion! of! child! domestic! workers! than! boys.2006,2007! In! 2002,! it! was! estimated! that! 59%! of! child!domestic!workers!were!girls!and!41%!were!boys.2008! In!2008,!Smucker,!Pierre,!and!Tardieu! found!that!65%! of! restaveks& and! restavek5boarders! were! girls,! compared! to! 53%! of! children! who! were! not!restaveks&or!restavek5boarders!(Figure!141).2009,2010! In!contrast,!PAHO!stated!in!2007!that!up!to!75%!of!child!domestic!workers!in!Haiti!were!girls.2011!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!2006!R.!de!Silva`de`Alwis,!Legislative&reform&on&child&domestic&labor:&A&gender&analysis,!UNICEF!Division!of!Policy!and!Planning!(January!2007).!Available!at!http://www.unicef.org/policyanalysis/files/Leg_Reform_on_Child_Domestic_Labour(1).pdf!





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!Figure.141:.Percentage.of.restavek.and.nonTrestavek.children,.by.gender,.2008.

Gender! %.of.restavèk!children!(n.=.677)!

%!of.other.children!n.=.2.471!

Boys. 35! 47!Girls. 65! 53!Total. 100! 100!


!!Assessment!of!girls’!over`representation!among!child!domestic!workers!requires!a!corollary!analysis!of!urban!and!rural!dynamics!of!child!placement,!as!“the!gender!distribution!among!child!domestics!reflects!the! organization! of! work! in! more! general! terms…! (and)! … this! gendered! organization! of! work! is!mediated!by!the!urban`rural!dimension.”2012!Most!child!domestic!workers!are!found!in!rural!areas,!but!the! proportion! of! urban! and! rural! children! who!were! domestic! servants! was! approximately! equal! in!2002!and!2008.2013,2014!This!situation!is!due!to!the!fact!that!most!of!the!total!Haitian!population!lived!in!rural! areas! in! those! years.!As! the!proportion!of! the!population! living! in!urban!areas!has! since!passed!50%,!the!majority!of!child!domestic!servants!may!now!live!in!urban!areas.!In!2009,!in!fact,!Smucker!et&al.&found!that!Port`au`Prince!(and!the!Ouest!Department,!generally)!contained!the!largest!concentration!of!child! domestic!workers! in! Haiti.2015! Gender! disaggregation! by! urban! and! rural! status! reveals! that! the!overwhelming!majority!of!child!domestic!workers! in!urban!areas!are!girls.!Thus,!while!59%!of!all!child!domestic! workers! were! girls! in! 2002,! Sommerfelt! found! that! girls! comprised! 72%! of! child! domestic!workers!in!urban!areas,!and!53%!in!rural!areas,!though!these!proportions!varied!by!Department!(Figure!142).2016!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!2010!U.S.!Department!of!State,!Trafficking&in&persons&report&2009,!Office!to!Monitor!and!Combat!Trafficking!in!Persons!(June!2009).!Available!at!http://www.state.gov/documents/organization/123357.pdf!!










!


!Figure.142:.Distribution.of.child.domestic.workers.(thousands),.by.Department,.gender,.and.urban/rural.status,.2002.



!!The!significant!difference!between!the!proportion!of!child!domestic!workers!who!are!girls!in!urban!and!rural! areas!may! be! explained! by! the! types! of! work! generally! allocated! to!male! and! female! children,!discussed!in!greater!depth!below.!In!general,!girls!are!more!likely!to!be!allocated!work!associated!with!the! immediate!household,!such!as!cooking!and!washing!clothes,!while!boys!are!more! likely!to!work! in!agriculture!and!other!stereotypically!“masculine”!tasks.!This!gendered!allocation!of!work!is!more!clearly!delineated! in! rural! areas! than! urban! areas.! As! a! result,! the! approximate! gender! parity! among! child!domestic!workers!in!rural!areas,!in!contrast!to!urban!areas,!is!the!result!of!the!greater!need!for!labor!in!stereotypically!“masculine”!domains,!such!as!agriculture,!while!such!needs!are! less!prevalent! in!urban!areas.2017!!!Gendered! allocation! of! children’s! work! appears! to! impact! the! likelihood! that! child! domestic! workers!come!from!urban!or!rural!areas.!Overall,!the!proportion!of!child!domestic!workers!born!in!rural!areas!in!Sommerfelt’s! 2002! study! approximated! that! of! the! total! Haitian! population! (68%).! However,! gender!disaggregation!illustrates!that!male!child!domestic!workers!were!more!likely!to!have!been!born!in!rural!areas! (73%)! than! their! female!counterparts! (58%)! (Figure!143),! though! female!child!domestic!workers!



&



were! still! more! likely! to! have! been! born! in! rural! areas! than! urban! areas.2018! In! 2004,! Smucker! and!Murray!highlighted!an! increasing!trend! in! the!placement!of! rural!children! in!urban!households!“under!circumstances!that!allow!little&or&no&ongoing&contact&between&the&children&and&their&parents.”2019!!!Figure.143:.Place.of.birth.of.children.aged.5T17,.by.gender,.child.domestic.worker.status,.and.urban/rural.status,.2002.



!!As!Figure!137!illustrates,!8%!of!households!in!the!lowest!and!second`lowest!income!quintiles!contained!one! or!more! child! domestic!workers! in! 2002,! compared! to! 12%!of! households! in! the! highest! income!quintile.2020! Because! Smucker! et& al.! disaggregated! households! sending! and! receiving! restaveks! and!restavek5boarders!by!income!terciles,!rather!than!quintiles,!however,!it!is!difficult!to!determine!whether!the!proportion!of!children!placed!in!households!of!lower!socioeconomic!status!changed!over!the!period!2002!to!2008.!However,!the!Smucker!study!revealed!that!13%,!15%,!and!11%!of!households!with! low,!average,! and!high! socio`economic! status!had!placed!at! least!one!of! their! children!as!a! child!domestic!worker! in! another! household,! respectively! (Figure! 144),! and! that! 24%! of! households! of! low,! 31%! of!households!of!average,!and!36%!of!households!of!high!socio`economic!status!contained!a! restavek&or!restavek5boarder!(Figure!145).!!!As!previously!noted,!child!domestic!workers!are!placed! in!households!of!greater!socioeconomic!status!than! their! original! household,! and! households’! probability! of! containing! a! child! domestic! worker!increases! with! household! wealth.2021,2022,2023! As! a! result,! it! was! generally! believed! that! most! child!








!


domestic!workers!were!sent!from!poor!households!to!wealthy!households.2024!However,!research!over!the! past! decade! has! revealed! that! this! characterization! inadequately! explains! the! dynamics! of! child!placement.! Though! children! are! placed! with! households! of! greater! wealth! than! that! of! sending!households,!the!transition!is!not!from!“poor”!to!“wealthy”!households,!but!from!“poor”!to!“less!poor”!or!“less!affluent”!to!“more!affluent.”2025,2026,2027,2028!Though!households!of!higher!socioeconomic!status!are!1.5! times!as! likely! (36%)! to!contain!at! least!one! restavek&or! restavek5boarder! than! those!of! lower!socioeconomic!status! (24%),! the! finding! that!around!one!quarter!of!households!of! low!socioeconomic!status! also! contain! a! child! domestic! worker! supports! the! conclusion! that! children! are! placed! in!households! that!are!more!wealthy! that! the! sending!household,!but! that! the! receiving!household!may!only!be!marginally!more!affluent!that!the!sending!household.20292030!This! finding!may!also!explain!why!11%!of!households!of!high!socioeconomic!status!have!placed!their!child!in!another!household,!though!it!is! likely!that! improving!these!children’s!access!to!education!was!the!primary!motivation!for!placement!(restavek5boarders)! of! a! higher! proportion! of! these! children! than! of! children! of! lower! socioeconomic!status.!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!2022!G.!R.!Smucker!and!G.!F.!Murray,!The&uses&of&children:&A&study&of&trafficking&in&Haitian&children,!USAID/Haiti!Mission!(December!2004).!Available!at!http://pdf.usaid.gov/pdf_docs/PNADF061.pdf!!










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Figure.144:.Economic.status.of.households.placing.their.children.as.restaveks.and.restavek0boarders,.by.socioTeconomic.status,.2008.


!!Figure.145:.Economic.status.of.households.containing.restaveks.and.restavekTboarders,.by.socioTeconomic.status,.2008.


!!Sommerfelt’s! 2002! study! highlights! an! important! characteristic! of! household!wealth! and! households’!propensity!to!place!a!child!as!a!domestic!worker:!household!size.!Sommerfelt!notes!that!the!difference!between!the!average!yearly! incomes!of!households! that!have!placed!a!child! in!another!household! for&any& reason! and! those! that! have! not! is! relatively! small,! at! approximately! 400! gourdes! (Figure! 146).!However,!the!difference!is!greater,!although!still!relatively!small,!when!per&capita!household!income!is!

28

Economic� status� of� sending� and� receiving�

households.� To� what� extent� does� restavèk� sending�

and receiving cut across different economic levels in

low� income� urban� neighborhoods� studied?� The� basic�

assumption� of� restavèk� placement� is� that� wealthier�

households� are� less� likely� to� send� away� their� own�

children, and more likely to recruit restavèk children

for� their� own� use.� To� test� this� assumption,� the� study�

assesses the economic status of households to

test� correlations� between� varying� economic� levels�

and the propensity to send out or receive restavèk

children.

The� findings� in� Tables� 12-14� suggest� that� the� use�

of� servant� children� is� a� more� generalized� practice�

than expected. First of all, a certain percentage of

households� with� restavèk� children� have� also� placed�

their� own� children� in� domestic� service,� and� on� a�

scale� roughly� comparable� to� households� without�

restavèk� children� (11%� versus� 14%),� and� this� was�

true for all study sites (see Table 12).

In� other� words,� the� fact� of� having� a� restavèk� child�

does� not� mean� a� household� will� not� place� its� own�

children as restavèk servant children. The data also

reveal that 70% of the children sent into restavèk

placement� from� these� households� were� sent� to� other�

urban households.

Secondly,� Table� 13� shows� the� relative� economic�

status� of� households� that� have� sent� their� own�

children into restavèk placement. These households

show� relatively� little� difference� by� economic� status:�

11%� of� more� affluent� households� have� sent� away�

children� compared� to� 15%� and� 13%� of� low� and�

middle level households. Therefore, the practice

is cross-cutting in relation to the relative economic

status of households studied.

RESTAVÈK CHILDREN &HOUSEHOLD ECONOMIC STATUS

29

Table� 14� shows� a� neat� correlation� between� the�

percent� of� households� with� restavèk� children� and�

their relative economic status. Higher income

households� show� a� higher� restavèk� rate� (36%)�

compared� to� 24%� for� the� lower� tier,� and� 31%� for� mid-

range households. The differences are especially

significant� between� the� upper� and� lower� economic�

tiers.� This� finding� supports� the� longstanding�

hypothesis� that� the� flow� of� restavèk� children� is�

from� the� less� affluent� to� more� affluent� households,�

and from poor households to the less poor.

Table� 15� shows� the� same� overall� tendency� for�

all� cities� although� Gonaïves� has� a� 6%� difference�

in the opposite direction for the relatively more

affluent� households,� but� this� is� statistically� not� very�

significant.� In� Saint-Marc,� the� link� between� restavèk�

presence� and� more� affluent� economic� status� is� even�

higher;� only� 23%� of� low� income� households� have� a�

restavèk versus 61% for high income households. A

similar� pattern� holds� for� Petit-Goâve.�

!


assessed.!In!stark!contrast,!the!difference!between!the!per&capita!incomes!of!households!who!have!sent!a! child! to! another! household! to& perform& housework! and! those! that! have! not! are! greater! than! the!average! per& capita! incomes! of! sending! households! themselves! (Figure! 147).! In! fact,! the! difference!between! the! median! per& capita! incomes! of! those! households! that! have! sent! a! child! to! another!household!(1,239!HTG)!and!those!that!have!not!(2,643!HTG)!was!approximately!1,400!Haitian!gourdes!(HTG),!while!the!difference!in!mean!per&capita!incomes!(households!sending!a!child:!2,325,!households!not! sending! a! child:! 6,251)! was! around! 3,900! gourdes.2031! As! a! result,! per& capita! household! income!provides!a!more!detailed!characterization!of!the!situation!of!sending!and!non`sending!households!than!total!household!income,!and!illustrates!both!that!households!sending!a!child!to!another!household!for!the!purpose!of!domestic! labor!are! less!affluent!than!those!sending!a!child! for!other!reasons,!and!that!larger!households!are!more!likely!to!send!a!child!to!another!household!than!those!with!fewer!household!members.2032!!Figure.146:.Total.and.perTperson.mean.and.median.annual.household.income.(Gourdes),.by.whether.households.have.placed.a.child.in.another.household.for!any!reason,.2002.



!Figure.147:.Total.and.perTperson.mean.and.median.annual.household.income.(Gourdes),.by.whether.households.have.placed.a.child.in.another.household.to!perform!housework,.2002.



!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!2031!T.!Sommerfelt,!Child&domestic&labour&in&Haiti:&Characteristics,&contexts&and&organisation&of&children’s&residence,&




69

Po v e r t y : Reso lv i n g D i f f icu l t Si t u a t i o ns

When parents’ emphasise that they are “not capable” (pas kapab) to care for their children, they refer to their economic conditions. Jean Luc’s situation, as presented in Chapter 2, is a case in point. According to Jean Luc, he would never have sent his children to Port-au-Prince if he had been “capable” [of supporting them]. For him, their placement in new families was the solution in a difficult situation, even though he was aware that the children do not attend school. The children work for their up-keep in the new families, and Jean Luc is freed from these expenses. His incapability to provide for them derived from the fact that fishing did not yield sufficient output, and that he was the sole provider of his children after his first wife’s death and sec-ond wife’s leaving him.

Regarding parents’ poverty, differences in incomes between households that have and those that have not placed children in new homes have to be described. First, households that give away children have lower income than households that have not given away any children. This is the case for households that have given away chil-dren regardless of purpose (Table 17), but the difference is comparatively slight, about 400 Gourdes annually when household income is considered. When household income per person is considered, the difference becomes greater, reflecting that it is the large households that give away children.

More importantly, the difference in income between households that report no children given away for the purpose of housework and those that have given children away for housework is substantial (Table 18), when considering both total income and income per person. In this case, the total household income among providers of children is about half of the total household income in other households.

Tab le 17: Mean and med ian annua l total househo ld income ad justed for self-consumpt ion by

whether househo ld have g iven away ch ild , regard less of purpose (Gourdes)

Tota l Per person

Med ian Mean Med ian Mean

Has not g iven away ch ild 10 200 23 000 2 700 6 339

Has g iven away child 9 780 22 577 2 263 5 640

A ll 10 143 22 932 2 625 6 226

70

Tab le 18: Mean and med ian annua l total househo ld income ad justed for self-consumpt ion by

whether househo ld have g iven away ch ild for housework in another househo ld (Gourdes)

Tota l Per person

Med ian Mean Med ian Mean

Not g iven away ch ild 10 180 22 998 2 643 6 251

Has g iven away ch ild 4 600 12 339 1 239 2 325

A ll 10 143 22 932 2 625 6 226

Basically, these differences show that parents’ decisions to place their children in new homes are connected with their economic situation.22 However, poverty is not in itself sufficient to explain why parents choose to place their children in new homes. In Jean Luc’s case, a man who came to the village asked for his daughter, and this gave Jean Luc the opportunity to place his child. The “demand” for children sustains parents’ practice of placing them in new families – the social repertoire has domestic-ity to offer. Other factors also affect parents’ decisions concerning their children.

Asp ir i n g t o H i g h l y Tr e asu r e d V a l u es

Parents do not always express as clearly as did Jean Luc that they cannot cover their children’s basic needs, but simply state that they do not have means to send their children to school, and that they hope that the family with whom they have trusted the children will send them to school. In cases when receiving families do not send them to school, parents occasionally take their child back (an example of the latter was shown in the case of Jonise). Others try to find new families, who will send their child to school.

Hence, not only economic crisis, but also parents’ wish for their children’s educa-tion leads parents to place their children. The below case makes this abundantly clear:

M rs. Je a n n e Mrs. Jeanne is a woman in her mid-forties and a mother of six children, and lives in a small community near Jacmel. The father of her eldest child died when the child was only a year old. Her three other daughters and two sons are the children of her ex-husband, from whom she divorced two months ago.

22 We return to the issue of poverty when we later asses child domesticity in relation to inequality by way of a comparison of income levels in households that include child domestics and households that have placed children in new homes.

&



!A!key!finding!from!Smucker!et&al.’s!2009!study!was!that!receiving!a!restavek&or!restavek5boarder!does!not! indicate!whether,!or!preclude! the!possibility! that,!a!household!has!also!placed!one!or!more!of! its!own!children!as!a!restavek&or!restavek5boarder!in!another!household.!In!fact,!the!study!found!that!the!proportion!of!households!placing!a!child!as!a!domestic!worker!in!a!receiving!household!was!similar!for!those!households!that!contained!(11%)!and!did!not!contain!(14%)!a!restavek&or!restavek5boarder!(Figure!148).2033! This! finding! supports! the! conclusion! that! receiving! households!may!only! be!marginally!more!affluent!than!sending!households,!and!may!also!be!reflective!of!parents!sending!their!children!to!other!households!for!educational!purposes,!given!that!70%!of!surveyed!urban!children!sent!from!households!containing!a!child!domestic!worker!were!sent!to!another!urban!household.2034!

!Figure.148:.Percentage.of.households.receiving.restaveks.and.restavek0boarders,.by.sending.status,.2008.


!!

iii..Factors.motivating.placement.!The! factors!motivating! children’s! placement! as! domestic!workers! can! be! assessed!with! regard! to! the!needs,! desires,! and! expectations! of! the! child’s! parents,! the! child! him! or! herself,! and! of! the! receiving!household.!In!many!cases,!those!of!the!child!and!their!parent(s)!overlap,!while!others!may!be!specific!to!the!child!or!their!parent(s)!alone.!As!the!phenomenon!of!child!domestic!labor!placement!would!not!be!



28

Economic� status� of� sending� and� receiving�

households.� To� what� extent� does� restavèk� sending�

and receiving cut across different economic levels in

low� income� urban� neighborhoods� studied?� The� basic�

assumption� of� restavèk� placement� is� that� wealthier�

households� are� less� likely� to� send� away� their� own�

children, and more likely to recruit restavèk children

for� their� own� use.� To� test� this� assumption,� the� study�

assesses the economic status of households to

test� correlations� between� varying� economic� levels�

and the propensity to send out or receive restavèk

children.

The� findings� in� Tables� 12-14� suggest� that� the� use�

of� servant� children� is� a� more� generalized� practice�

than expected. First of all, a certain percentage of

households� with� restavèk� children� have� also� placed�

their� own� children� in� domestic� service,� and� on� a�

scale� roughly� comparable� to� households� without�

restavèk� children� (11%� versus� 14%),� and� this� was�

true for all study sites (see Table 12).

In� other� words,� the� fact� of� having� a� restavèk� child�

does� not� mean� a� household� will� not� place� its� own�

children as restavèk servant children. The data also

reveal that 70% of the children sent into restavèk

placement� from� these� households� were� sent� to� other�

urban households.

Secondly,� Table� 13� shows� the� relative� economic�

status� of� households� that� have� sent� their� own�

children into restavèk placement. These households

show� relatively� little� difference� by� economic� status:�

11%� of� more� affluent� households� have� sent� away�

children� compared� to� 15%� and� 13%� of� low� and�

middle level households. Therefore, the practice

is cross-cutting in relation to the relative economic

status of households studied.

RESTAVÈK CHILDREN &HOUSEHOLD ECONOMIC STATUS

!


possible!without!a!receiving!household,!it!is!also!necessary!to!examine!why!receiving!households!accept!or!seek!child!domestic!servants.!!In!her! report! to! the!General!Assembly!on!child!domestic! labor! in!Haiti,! the!UN!Special!Rapporteur!on!contemporary! forms! of! slavery,! including! its! causes! and! consequences,! stated! that! restavek! children!(and,!it!may!be!inferred,!child!domestic!servants!generally),!“are!children!who!are!given!by!their!families!to!more!affluent!families,! in!the!hope!that!they!will!be!provided!with!food,!clothing,!shelter,!schooling!and!health!care!in!return!for!their!domestic!labour.”2035!This!characterization!incorporates!many!aspects!of!the!factors!motivating!children’s!placement!as!domestic!servants,!including!the!exchange!of!children’s!labor! for! upkeep! and! caretaking,! the! comparative! affluence! of! receiving! households,! common!expectations!of!treatment,!and!the!fact!that!most!arrangements!are!based!on!the!hope,!rather!than!any!formal!guarantee,!of!children’s!positive!experiences.!Additionally,! it! reflects!the!fact!that!parents!view!placement! as! a! means! both! to! fulfill! their! children’s! current! needs! and! to! expand! their! range! of!opportunities.2036!!!Parents’! decisions! to! place! a! child! in! another! household! are! generally! motivated! by! two! primary!considerations:!1)!the!child’s!familial!household!is!unable!to!provide!for!them,!and!2)!the!hope!that!the!child!will!have!greater!access!to!education!in!the!receiving!household.2037,2038,2039,2040!In!one!sense,!these!two!motivations!can!be!seen!as!“push”!and!“pull”! factors:! inability! to!provide! for! their!child!“pushes”!parents! to! search! for! strategies! in!which! the! child’s! basic! needs! can!be!met,!while! the!hope! that! the!child! will! have! greater! access! to! education! incentivizes,! or! “pulls”! the! child! towards,! placement! in!another! household.2041! As! discussed! in! Section! 6A.& Monetary& poverty,! most! Haitians! live! below! the!poverty! line,! severely!affecting! their!ability! to!provide! for! their! children’s!basic!needs,!and!exposing!a!significant! proportion! of! Haitian! children! to! greater! risk! of! placement! as! domestic!workers.! Similarly,!inadequate!access!to!education!in!rural!areas!(discussed!further!in!Section!8E.&Access&to&education&and&barriers& to& enrollment)! has! been! cited! as! the! dominant! motivation! for! rural! children’s! placement! as!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!2035!UN!GA,!Report!of!the!special!rapporteur!on!contemporary!forms!of!slavery,!including!its!causes!and!consequences,!Gulnara!Shahinian,!UN!Doc.!A/HRC/12/21/Add.1!(2009).!Available!at!http://www.unhcr.org/refworld/docid/4ac0c6b42.html!









&



restaveks!in!urban!households—although!relatively!few!children!placed!as!domestic!servants!will!receive!education!during!their!placement.2042!!The!two!primary!motivations!for!child!placement—poverty!and!inability!to!provide!for!the!child’s!basic!needs!on!the!one!hand,!and!parents!desire!to!expand!the!child’s!access!to!education!on!the!other—are!intimately! related.! Education! is! highly! valued! in! Haitian! society.! As! a! result,! Haitian! families! spend! a!significant! proportion! of! household! income! on! school! fees! and! education! (described! in! Section! 8E.&Access&to&education&and&barriers&to&enrollment),!leaving!little!for!other!basic!expenses.!The!impact!of!this!on!a!family’s!ability!to!provide!for!children’s!needs!is!magnified!in!large!households!and!those!of!lower!socioeconomic!status.!Inversely,!household!poverty!is!itself!a!risk!factor!for!children’s!nonènrollment!in!school,!compelling!parents!to!search!for!alternative!situations! in!which!the!child!has!greater!access!to!education.2043!!Though!household!poverty!and!the!search!for!children’s!access!to!education!constitute!the!two!primary!motivations! for! the!placement!of! children! in!other!households,!de!Silva`deÀlwis!has!also!described!a!broader!range!of!interrelated!risk!factors!for!child!relinquishment:!!

Continued!poverty;! illiteracy!and!ignorance!of!poor!parents;! increase!in!population;! inadequate!family!income;!large!families;!indebtedness;!absence!of!social!security!schemes;!and!lack!of!strict!enforcement! of! the! provisions! for! compulsory! education;!migration! from! rural! areas! to! urban!areas;!the!cheap!costs!of!child!domestic! labour!all!contribute!to!child!domestic! labour.!Further,!families!plagued!by!dysfunction,!abandonment,!violence,!alcohol,!drug!abuse!can!push!children!early!into!work.!Economic!transition!both!in!and!outside!the!home!can!contribute!to!the!rise!in!child!domestic!labour.!When!adults!are!struck!by!life!threatening!diseases!like!HIV/AIDS!children!are!forced!to!carry!the!burden!of!extra!household!work!and!or!go!out!to!work.2044&

!De!Silva`deÀlwis!highlighted!a!determinant!of!child!placement!that!is!often!overlooked!in!discussions!of!child!domestic! service! in!Haiti:! the! importance!of!precipitating!events,! such!as! the!death!of! a!parent,!that!catalyze!an!acute!perceived!need! for!a!child! to!be!placed! in!another!household.!Sommerfelt!also!noted! in! 2002! that! cases! in! which! children! themselves! initiate! their! placement! as! domestic! servants!usually! follow!the!disintegration!of! their!original!household!due! to!parental!death!or!other!causes.2045!This!conclusion!is!supported!by!Smucker!and!Murray’s!2004!research,!which!showed!that!the!majority!of!




2044!R.!de!Silva`deÀlwis,!Legislative&reform&on&child&domestic&labor:&A&gender&analysis,!UNICEF!Division!of!Policy!and!Planning!(January!2007).!Available!at!http://www.unicef.org/policyanalysis/files/Leg_Reform_on_Child_Domestic_Labour(1).pdf!



!


studied!restavek!placements!had!occurred!within!one!year!of!the!death!of!another!household!member,!usually!a!parent.2046!This!finding!is!of!particular!concern!following!the!January!2010!earthquake,!as!one!in!every!five!Haitian!households!experienced!the!death!of!a!family!member!and!many!more!were!thrust!further!into!poverty,2047!potentially!increasing!the!proportion!of!Haiti’s!children!at!risk!of!placement!as!child!domestic!servants.!!Child!placement!agreements!are!initiated!by!both!sending!and!receiving!households,!and,!occasionally,!by!children!themselves.!As!noted!previously,! familial!networks!constitute!the!primary!avenue!for!child!placement.!In!2002,!85.8%!of!child!domestic!workers!were!related!to!the!head!of!receiving!households!nationwide! (Figure! 133,! page! 308),2048! while! the! same! was! true! of! 78%! of! restaveks! and! restavek5boarders! in! urban! areas! in! 2008! (Figure! 134,! page! 309).2049! In! contrast! to! the! multi`dimensional!motivations! of! parents! to! place! their! children! in! other! households,! Sommerfelt! has! stated! that!households!searching!for!child!domestic!workers!typically!reference!their!“need”!for!a!child!to!perform!household! tasks,! and! acquiring! labor! may! be! the! only! factor! motivating! their! search,! rather! than!“assisting”! the! child! or! consolidating! kinship! ties.! As! a! result,! children!who! are! unable! to! fulfill! these!needs!may!be!sent!back!to!their!original!families.2050!!!Situations!in!which!a!child’s!placement!is!initiated!by!children!themselves!usually!occur!as!a!result!of!the!disintegration! of! the! children’s! family! unit,! when! the! child’s! situation! in! their! familial! household!becomes!“unbearable,”!or!sometimes!in!the!search!of!a!new!employer/guardian!when!they!have!been!mistreated!within!a!receiving!household.2051!Child!domestic!servants’!risk!of!mistreatment!and!neglect!is!discussed! in! further! detail,! below.! However,! it! should! be! noted! that! a! child’s! ability! to! change!households!depends!upon!their!agency,!and!many!child!domestic!workers!in!situations!of!servitude!may!be!unable!to!negotiate!an!end!to,!or!escape!from,!their!current!placement.!!Two!recent!interrelated!trends!have!been!observed!with!respect!to!ways!in!which!children!are!placed!as!domestic! workers.! As! previously! noted,! the! proportion! of! child! domestic! workers! in! households!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!2046!G.!R.!Smucker!and!G.!F.!Murray,!The&uses&of&children:&A&study&of&trafficking&in&Haitian&children,!USAID/Haiti!Mission!(December!2004).!Available!at!http://pdf.usaid.gov/pdf_docs/PNADF061.pdf!









&



containing!a! relative!has! fallen!over! time,! such! that!an! increasing!proportion!of! these!children!do!not!have!familial!ties!to!their!host!household.2052,2053,2054,2055!This!increase!in!the!proportion!of!children!in!the!service!of!strangers!has!been!driven!by!the!parallel!increasing!trend!of!sending!and!receiving!families!to!employ! a!middle`man,! or! “koutye”! to! arrange! child! placements,! especially! in! the! placement! of! rural!children!in!urban!households.2056,2057,2058,2059!Sommerfelt!has!observed!that!the!perceived!need!for!such!middle`men!“is!a!result!of!a!common!complaint!among!receiving!families!that!it!is!difficult!to!‘get!good!children!these!days.’”2060!In!2002,!koutyes!were!paid!around!50!gourdes!by!the!family!receiving!a!child!domestic!worker,!but!were!not!paid!by!the!sending!household!or!the!child,!as!is!the!case!for!placements!involving!adult!servants.2061,2062!

!!!

iv..Risk.factors.and.outcomes.of.child.domestic.service.&

Children! in! domestic! service! and! servitude! in! Haiti! face! significant! risks! to! their! health;! access! to!education;!and!physical,!mental,!moral,!and!social!development,!in!contravention!of!Article!32!of!the!UN!
















!


Convention!on!the!Rights!of!the!Child2063!(to!which!Haiti!became!a!state!party!in!June!1995)2064!and!other!national!and!international!legal!instruments.!As!previously!noted,!children’s!risks!vary!both!between!and!within!categories!of!domestic!service!placement!arrangements.2065,2066!However,!successive!studies!have!revealed! that! children! in! domestic! service,! including! those! whose! placement! was! conditional! on! the!child’s!school!attendance,!face!significant!risks!of!exploitation,!abuse,!neglect,!and!deprivation!of!rights!and!basic!needs,!including!access!to!education.2067,2068,2069,2070,2071,2072,2073,2074!The!risks!faced!by!children!in!domestic! service! and! servitude! largely! depend!on! the! economic! status! and! financial! resources! of! the!sending! household,! the! terms! and! formality! of! the! placement! agreement! between! the! sending! and!receiving!household,!the!types!and!intensity!of!work!performed!by!the!child,!the!frequency!of!contact!between! the! child! and! their! parent(s),! and! the! receiving! household’s! propensity! to! treat! the! child!differently! than! its! biological! children.2075,2076! Though! the! negotiated! terms! and! formality! of! the!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!2063!Convention!on!the!Rights!of!the!Child,!G.!A.!Res.!44/25!(1989).!Available!at!http://www2.ohchr.org/english/law/crc.htm!

2064!UN!Treaty!Collection,!Status:&Convention&on&the&rights&of&the&child!(2011).!Available!at!http://treaties.un.org/Pages/ViewDetails.aspx?src=IND&mtdsg_no=IV`11&chapter=4&lang=en!!









2071!R.!de!Silva`de`Alwis,!Legislative&reform&on&child&domestic&labor:&A&gender&analysis,!UNICEF!Division!of!Policy!and!Planning!(January!2007).!Available!at!http://www.unicef.org/policyanalysis/files/Leg_Reform_on_Child_Domestic_Labour(1).pdf!







&



placement! agreement! between! sending! and! receiving! households! are! key! determinants! of! children’s!risks,! they! are! by! no! means! a! panacea,! and! neither! placement! agreements! nor! kinship! ties! can!guarantee!the!wellbeing!of!a!child!domestic!worker.2077,2078!Placing!children!in!receiving!households!that!are! only!marginally! less! poor! than! sending! households! also! compromises! the! fulfillment! of! children’s!rights,!as!does!the!increasing!prevalence!of!placements!that!offer!little!or!no!contact!between!children!and!their!parents.2079,2080!As!a!result,!Smucker,!Pierre,!and!Tardieu!noted!in!2009!that!restavek!treatment!and!victimization!affect!more!Haitian!children!than!any!other!form!of!child!victimization,!with!significant!consequences!for!future!generations.2081!!Child!domestic!workers’!risks!and!vulnerabilities!are!examined!here!in!terms!of!“active”!abuse,!including!physical,! sexual,! and! psychosocial! abuse,! and! “passive”! neglect,! exclusion,! and! lack! of! commensality.!This!examination!will!begin!with!an!analysis!of!child!domestic!workers’!interrelated!experiences!of!work!and!access!to!education,!given!the!fundamental!role!of!these!experiences!in!motivating!and!defining!the!placement!of!children!as!domestic!workers!before!exploring!the!risks!and!manifestations!of!abuse!and!neglect!confronted!by!these!children.!!Child!domestic!servant’s! labor!tasks!are!tied!to!the!household!sphere!and!economy,!and! include!tasks!such!as!collecting!water,!running!errands,!washing!clothes,!preparing!food,!and!assisting!with!agriculture!and! livestock! in! rural! areas.! As! almost! all!Haitian! children! are! expected! to! perform!domestic!work! of!some!kind,!Sommerfelt’s!2002!study!found!that!“[t]here!is!no!activity!that! is!carried!out!exclusively!by!child!domestic!workers!(Figure!149).”2082!However,!child!domestic!workers!were!more!likely!to!perform!every!activity!surveyed!than!other!children,!except!for!focusing!on!education,!and!the!average!number!of!tasks!performed!by!child!domestic!workers!was!higher!than!that!of!other!children.2083!!












!


Figure.149:.Activities.performed.by.child.domestic.workers.and.other.children.during.the.preceding.year,.2002.



!!In!2009,!Smucker,!Pierre,!and!Tardieu!confirmed!that!child!domestic!workers!perform!more!tasks!than!other!children!with!the!finding!that!these!children!were!assigned!almost!twice!the!number!of!chores!as!other!children!in!the!household!(Figure!150).!Smucker!et&al.!also!found!that!children!placed!as!boarders!(for!the!explicit!and!primary!purpose!of! improving!their!access!to!school)!were!“generally!expected!to!perform! chores! consistent! with! the! level! of! support! or! non`support! from! their! own! parents.”2084! As!pervasive! poverty! limited! parents’! ability! to! send! money! and! goods! to! receiving! households,! most!boarders! (classified!as!“restavek`boarders”!by! the!study! team)!were!also! required! to!perform!a!heavy!workload!to!“compensate”!the!host!household!for!their!upkeep.!Analysis!of!work!assignments!revealed!that!restavek5boarders!were!required!to!perform!similar!amounts!of!work!to!that!of!restavek!children,!indicating! that! placements! conditioned! on! school! attendance! did! not! preclude! heavy! workloads! in!addition!to!studies.2085!!



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Figure.150:.Average.number.of.restavek.and.nonTrestavek.chores,.by.surveyed.site,.2008.

SITE Number of chores

assigned to the ''pitit kay''* Number of chores

assigned to ''restavèk'' Average N Average N Carf. Feuilles / Fontamara / Martissant 3.2

109 5.7 41

Solino / Bel-Air 2.4 205 5.4 50 Cité Soleil 3.2 114 5.8 24 Delmas / Tabarre 2.8 122 5.6 35 Mon Repos / Lamentin 3.2 114 5.5 24 Cap-Haitian 3.6 246 5.8 46 Gonaïves 4.4 152 6.6 27 Saint-Marc 3.8 111 5.6 37 Petit-Goâve 3.0 111 4.9 17 Total 3.3 1284 5.7 301

*!“Child!of!the!home”!(non`restavek)!Source:!G.!R.!Smucker,!Y.!F.!Pierre,!and!J.!F.!Tardieu,!Lost&childhoods&in&Haiti:&Quantifying&child&trafficking,&restavèks,&&&victims&of&violence,!Pan!American!Development!Foundation!Protecting!Human!Rights!Project!(November!2009).!Available!at!http://www.crin.org/docs/Haiti_lost_childhoods.pdf!!

!!As!previously!noted,!the!tasks!performed!by!child!domestic!workers!are!mediated!by!the!child’s!gender!and! whether! the! receiving! household! is! in! an! urban! or! rural! area.! Figure! 151! shows! that! cooking,!washing!clothes,!and!other!tasks!most!closely!related!to!the!house!are!more!often!the!responsibility!of!female!child!domestic!workers,!while!tasks!such!as!assisting!adults,!tending!to!livestock,!and!performing!additional!agricultural!activities!were!more!commonly!allocated!to!boys.!Overall,!female!child!domestic!workers!generally!perform!a!wider!range!of!tasks!than!their!male!counterparts.2086!!


!


Figure.151:.Activities.performed.by.child.domestic.workers.during.the.preceding.week,.by.sex.and.urban/rural.status,.2002.



!!Of!fundamental!importance!to!understanding!child!domestic!servants’!experiences!of,!and!risks!due!to,!their!work! in! receiving!households! is! the! intensity! (number!of!hours)!of! their! labor,! in!addition! to! the!tasks! they!perform.!Figure!152! illustrates! the!average!number!of!hours!worked!by!all!children! in!each!labor!intensity!quintile!in!2002!by!age!group.!Haitian!children!are!expected!to!perform!household!work!at!a!very!young!age,!and!children!in!higher!labor!intensity!quintiles!spend!a!significant!portion!of!their!time!performing!household!tasks.!!!!!!

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Figure.152:.Children's.weekly.workload,.in.approximate.quintiles.of.hours.worked,.by.age,.2002.



!!Though!Figure!152!shows!that!Haitian!children,!in!general,!spend!significant!time!performing!household!work,! it! does! not! indicate! what! proportion! of! children! with! a! heavy! workload! are! child! domestic!workers.! Multiple! fora! have! revealed! that! children! in! domestic! service! perform! significantly! more!household!work!than!other!children.!De!Silva`de`Alwis!has!stated!that!children!in!domestic!service!and!servitude!“work!long!hours!under!extreme!conditions.”2087!The!UN!Special!Rapporteur!on!contemporary!forms!of!slavery!noted!with!concern!that!children!in!domestic!servitude!are!economically!exploited!and!assigned!heavy!workloads!by!receiving!households.2088!According!to!the!U.S.!Department!of!Labor,!the!majority!of!restaveks!work!between!10!and!14!hours!per!day.2089!Sommerfelt’s!2002!assessment!found!lower! estimates! of! the! number! of! hours! child! domestic! servants! worked! during! the! preceding! week!(Figure!153)!than!those!cited!by!the!U.S.!Labor!Department,!but!highlighted!significant!differences!in!the!number!of!hours!of!work!performed!by!child!domestic!workers!and!other!children!in!all!categories,!by!age.2090! As! such,! it! is! likely! that! the!majority! of! all! children!with! higher!workloads! are! child! domestic!servants,! even! given! that! child! domestic! workers! comprise! a! minority! of! all! Haitian! children.! For!operational!purposes,!a!heavy!workload! is!often!used! in!the!classification!of!children!as!restaveks!and!child!domestic!workers.!As!a!result,!such!children!will,!by!definition,!have!higher!workloads!than!other!children.!However,! the!marked! intensity!of!work!performed!by!child!domestic!servants,!as!well!as! the!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!2087!R.!de!Silva`de`Alwis,!Legislative&reform&on&child&domestic&labor:&A&gender&analysis,!UNICEF!Division!of!Policy!and!Planning!(January!2007).!Available!at!http://www.unicef.org/policyanalysis/files/Leg_Reform_on_Child_Domestic_Labour(1).pdf!





35

Tab le 3: Ch ildren’s weekly workload , in approximate qu int iles of hours worked , by age

Approximate qu int ile

Age group (years) 1 2 3 4 5 Med ian

3 – 5 0 0 0 1 – 3 4 + 0

6 – 8 0 0 1 – 2 3 - 9 10 + 1

9 – 11 0 1 – 2 3 – 7 8 - 19 20 + 5

12 – 14 0 1 – 5 6 - 12 13 -27 28 + 8

15 – 17 0 1 – 7 8 - 16 17 - 33 34 + 11

One way to depict the simultaneous relation between residence, work and education is through correspondence analysis. This multivariate qualitative statistical technique aims at showing the association between several characteristics as a Cartesian graph, where the characteristics that are located close to each other on the plot go together. Thus, on the plot, it is clear that belonging to the group of children that does the least work, goes together with the focus on education, and also actual attendance. Put differently, children who do the least work are to a great extent the same as those who focus on their education and actually attend school. In general, there is a ten-dency too that small workload goes together with attending school, and few house-hold chores (upper left quadrant of the plot), while in the lower right quadrant is found work and non-attendance.

While the figure does give support to the notion that work and school are contra-dictory activities, it is perhaps surprising that the child’s residence with or without his or her parents does not make much of a difference for work or schooling. There are at least two possible interpretations: first, some children are sent away in order to go to school. Secondly, Haitian children who live with there parents also work.

The above does not mean that residence is irrelevant, it simple underlines the fact that several criteria are needed in order to identify the child domestic workers, and that being a domestic worker is not the only vulnerability a Haitian child may face.

Th e N u m b e r o f C h i l d D o m est ic W o r ke rs

If we combine the three characteristics: residence, school and work, we find that 173 000 children, or 8.2 percent of the child population aged five to 17 years can be considered child domestic workers. Obviously, the few below-eighteens that have established their own households are excluded. For estimation purposes we consid-ered those children having a workload belonging to one of the three highest groups

!


additional!and!consequential!deprivation!of!other!rights!due!to!their!heavy!workloads,!highlights!their!particularly!high!risk!of!exploitation,!abuse,!neglect,!and!impaired!development.!!Figure.153:.Median.number.of.hours.worked.in.the.household.during.the.preceding.week,.by.child.domestic.worker.status,.sex,.age,.and.urban/rural.status,.2002.



!!The! high! workloads! of! children! in! domestic! service! contribute! to! their! deprivation! of! other! rights,!particularly! the! right! to! education.! Like! responsibility! for! a! heavy! workload,! differential! access! to!education!is!often!used!as!an!indicator!to!categorize!children!as!restaveks!and!child!domestic!workers.!As!such,!school!enrollment!among!these!children!will!always!be!lower!than!that!of!other!children!in!the!same!household!when!this! indicator! is!used!to!characterize!the!child!placement!arrangement.!Despite!this! limitation,! available! evidence! confirms! that! many! child! domestic! servants! are! systematically!deprived!of!their!right!to!schooling,!and!that!the!heavy!workloads!assigned!by!host!households!interfere!with! their! education,! in! contravention! of! Article! 32! of! the! Convention! on! the! Rights! of! the!Child.2091,2092,2093,2094,2095,2096!!








51

Tab le 10 Med ian number of hours worked in the househo ld last week

Urban Rura l ALL

Male Fema le Ma le Fema le

Age-group Non CDW CDW Non CDW CDW Non CDW CDW Non CDW CDW

5-6 0 1 0 10 0 5 0 8 0

7-8 1 4 0 8 2 8 3 6 2

9-10 1 4 1 14 4 10 6 19 4

11-12 1 16 4 16 6 19 11 21 7

13-14 2 11 6 23 8 25 12 20 9

15-17 3 22 7 31 9 21 19 33 11

As can be seen from Table 10, female child domestic workers work more than male. Furthermore, the median of hours worked last week is profoundly higher among child domestics than non-child domestics. As mentioned, this is partly related to the definition used to estimate the extent of child domesticity.

In sum, a main characteristic of child domestics is that they participate in all work activities in the household, and that education is the only activity in which they en-gage less than other children.

E d uca t i o n

Educational level was used as one of the criteria for defining child domestic workers, and the enrolment ratio among child domestics is therefore lower than among other children. Nevertheless, there are differences within the group of child domestics. Figure 9 shows that there is a difference between the female and male child domestic workers. For the boys, the enrolment rate increases by age all the way up to 17 years, whereas for the girl domestics, the enrolment rate decreases form the age of 14.

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!Again,!it!is!important!to!note!that!child!domestic!servants’!access!to!education!is!heavily!influenced!by!the! terms!and! formality!of! the!placement!agreement!between!sending!and!receiving!households,!and!the!financial!resources!of!the!child’s!family,!among!other!factors.!Those!children!whose!placement!was!conditional!on!school!access!and!whose!families!are!able!to!pay!the!receiving!household!for!the!child’s!upkeep!and!educational!expenses!are!more!likely!than!other!children!to!be!enrolled!in!school.!However,!as! suggested! by! the! UN! Special! Rapporteur! on! contemporary! forms! of! slavery,! the!majority! of! child!placements!are!based!on!the!hope!that!the!child!will!be!sent!to!school,!rather!than!its!formal!guarantee.!As!a!result,!children!in!domestic!service!are!often!either!deprived!of!enrollment!entirely,!or!enrolled!in!schools!of!inferior!quality!than!those!attended!by!other!household!children.2097,2098,2099!!In!2002,!it!was!found!that!child!domestic!workers!were!almost!half!as!likely!to!spend!time!“focusing!on!their!education”!than!other!household!children!(Figure!149,!page!332).2100!Urban!child!domestic!workers!were!more! likely! to! report! spending! time! focusing! on! education! than! their! rural! counterparts,! while!urban!female!domestic!workers!were!more!than!twice!as!likely!(30.2%)!to!spend!time!focusing!on!their!education! than!their!urban!male!counterparts! (13.8%)! (Figure!151,!page!334).!Child!domestic!workers!were!less!likely!to!be!enrolled!in!school!than!other!household!children!at!every!age!in!2002!(Figure!154).!Additionally,! child! domestic! workers! were! more! than! twice! as! likely! to! have! never! attended! school!(29%),!not!currently!be!enrolled!(11%),!or!be!enrolled!in!a!lower!grade!than!their!age!implies!(60%)!as!children!who!were!not!living!with!their!parents!but!were!not!child!domestic!workers!(10%,!4%,!and!25%,!respectively),!and!almost!twice!as!likely!to!exhibit!each!of!these!educational!deficits!than!children!living!with!their!parents!(Figure!155).2101!!









!


Figure.154:.Percentage.of.children.enrolled.in.school,.by.child.domestic.worker.status,.age,.and.sex,.2002.

!*Blue!line!represents!percentage!currently!enrolled,!pink!line!represents!overall!enrollment.!Source:!T.!Sommerfelt,!Child&domestic&labour&in&Haiti:&Characteristics,&contexts&and&organisation&of&children’s&


!!Figure.155:.School.enrollment,.by.residence.with.parents.and.child.domestic.worker.status,.2002.



!!

52

Figure 9: Percentage of ch ildren enro lled by age accord ing to sex and ch ild domest ic worker-status

(Bo ld line sign ifies percentage current ly enro lled , grey line sign ifies overall current enro lment)

However, overall enrolment is not much different between male and female domestic child workers, either in urban or rural areas.

A comparison between children living with and without their parents and child domestic workers is also important. As it is part of the definition, child domestic workers score lowest on enrolment. At the same time, however, other children who live away from their parents (i.e. who are not identified as child domestic workers), have higher and better enrolment than children who live with their parents (Table 11).

Boy non-CDW

0

10

20

30

40

50

60

70

80

90

Boy CDW

0

10

20

30

40

50

60

70

80

90

5 6 7 8 9 10 11 12 13 14 15 16 17

G irl non-CDW

G irl CDW

5 6 7 8 9 10 11 12 13 14 15 16 17

53

Tab le 11: Enro lment by residence w ith parents and ch ild domest ic worker status

Not living w ith parents

Not child domest ic worker Child domest ic worker Living w ith parents A ll

Never attended school 10 29 16 16

Not current ly enro lled 4 11 5 6

Enrolled at lower grade than age imp lies 25 60 38 38

Enrolled at correct grade for age 61 41 40

A ll 100 100 100 100

Unweighted Va lid N 1 160 862 8 444 10 466

This pattern lends credence to the parents’ contention that children are sometimes sent away to ensure their education. The non-child domestics who live away from their parents who are identified here as having higher and better enrolment than chil-dren who live with their parents may be living in arrangements of “paid board”, as described in Chapter 2.

In sum, the combination of heavier workload and lower enrolment contributes to the image of child domestic workers as a vulnerable group. Within the group of child domestics, it is difficult to determine the effects of girls’ heavier workload on their educational situation and prospects, particularly because we find that urban girls fo-cus more on their education than the other categories of child domestics.

Cl o t h i n g , H o u rs o f Sle e p , H e a l t h a n d Pa r e n t a l C o n t ac t

Turning to other indicators of living conditions, we find that in urban areas, children who are not child domestics receive new clothes more often than child domestic workers.

Tab le 12 Percentage that received new clothes last three months

Urban Rural

Non-CDW CDW Non-CDW CDW

Ma le 19 .0 16 .2 12 .9 12.3

Female 19 .8 12 .7 15 .0 16.5

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Low!and! inferior! school! enrollment! among! child! domestic!workers! can!be!observed! in! fewer! average!years! of! education! completed! compared! to! other! children.! Data! collected! by! Smucker,! Pierre,! and!Tardieu!in!2008!revealed!than!non`restavek!children!in!troubled!urban!neighborhoods!of!Port`au`Prince,!Cap`Haïtien,!Gonaïves,! Saint`Marc,! and! Petit`Gôave! had! completed! almost! two! years!more! education!than! restavek! children! (Figure!156).!Differential! levels! of! educational! attainment!were!observed! in! all!surveyed! sites,! with! the! greatest! difference! observed! in! Solino/Bel`Air! (2.3! years).2102! Children! in!domestic! service! and! servitude! are,! therefore,! both! less! likely! to! be! enrolled! in! school,! and! attain! a!lower!level!of!education,!than!other!household!children.!!Figure.156:.Average.years.of.schooling.of.restavek.and.nonTrestavek.children,.by.surveyed.site,.2008.

CITY

Average schooling of a non-restavèk

child (pitit kay)

Number of non-restavèk children (pitit

kay)

Average schooling

for restavèk

Number of restavèk children

Carrefour Feuilles / Fontamara / Martissant 6.0 117 4.0 76

Solino / Bel-Air 6.3 212 4.0 96 Cité Soleil 5.5 115 4.5 34 Delmas / Tabarre 6.5 123 4.4 50 Mon Repos / Lamentin 7.7 116 5.5 37 Cap-Haïtien 6.3 245 4.4 61 Gonaïves 5.9 153 4.7 39 Saint-Marc 5.8 116 4.7 45 Petit-Goâve 6.0 111 4.0 25 Total 6.22 1308 4.37 463


!!Smucker! et& al,! contend! that! education! is! an! “effective!measure! to! prevent! restavek! placement,! and!educating!restavèk!children!can!effectively!alleviate!the!effects!of!restavèk!placement,!foreshorten!the!amount!of!time!children!remain!in!restavèk!placement,!and!reduce!the!likelihood!of!inter`generational!child! domesticity.”2103! In! addition! to! the! intergenerational! effects! of! educating! children! in! domestic!servitude,! school! enrollment! also! improves! the! ability! of! these! children! to! access! social! services! and!



!


facilitates! the!monitoring! of! their! domestic! treatment.2104! As! a! result,! non`enrollment! of! a! significant!proportion!of!child!domestic!workers!increases!their!risk!of!abuse!and!neglect!within!host!households,!while!also!limiting!their!ability!to!access!assistive!and!remedial!services.!!Children! in! domestic! service! and! servitude! experience! systematic! risks! of! physical,! psychological,! and!sexual!abuse.2105,2106,2107,2108,2109!As!noted!previously,!despite!comprising!a!minority!of!all!Haitian!children,!Smucker!et&al!has!stated!that!victimization!as!a!result!of!restavek!treatment!“affects!far!more!children!than! other! forms! of! victimization! studied.”2110! Such! widespread! abuse! and! victimization! of! child!domestic!workers!carries!significant! intergenerational!consequences,!as!parents!who!were!abused!and!denied! affection! during! childhood!may! perpetuate!mistreatment,! while! their! lack! of! educational! and!economic! opportunities! may! result! in! intergenerational! cycles! of! poverty! and! child! domestic!placement.2111,2112!!Characterizations! of! “difficult! circumstances”! reported! by! child! domestic! workers! primarily! relate! to!being!beaten!and!punished!by!adults,!and!sometimes!other!children,!in!their!host!household.2113,2114,2115!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!2104!G.!R.!Smucker,!Y.!F.!Pierre,!and!J.!F.!Tardieu,!Lost&childhoods&in&Haiti:&Quantifying&child&trafficking,&restavèks,&&&victims&of&violence,!Pan!American!Development!Foundation!Protecting!Human!Rights!Project!(November!2009).!Available!at!http://www.crin.org/docs/Haiti_lost_childhoods.pdf!!















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Discipline!and!harsh!treatment!of!child!domestic!workers! is!often!motivated!by!the!perceived!need!to!“put! the! child! in! place”! through! asserting! control! and! dominance,! for! fear! that! the! situation! will!otherwise!“get!out!of!hand.”2116!As!a!result,!Sommerfelt!observed!in!2002!that!“children’s!insistence!on!rights!is!read!as!expressions!of!a!situation!about!to!get!out!of!control,!which!triggers!ever!new!cycles!of!sanctioning.”2117!!Analysis!of!data!from!the!2001!Haiti!Living!Conditions!Survey!reveals!the!finding!that,!despite!high!rates!of!corporal!punishment!and!violence!overall,!the!methods!of!punishment!experienced!by!child!domestic!workers! during! the! week! preceding! the! survey! were! comparable! to! those! of! other! children! in! the!household,! with! some! variation! between! sex! and! urban/rural! status! (Figure! 157! and! Figure! 158).! In!contrast,!the!UN!Special!Rapporteur!on!contemporary!forms!of!slavery!and!Smucker!et&al.’s!2009!study!found!that!child!domestic!workers!were!at!greater!risk!of!physical!abuse!and!mistreatment!than!other!children,!and!that!70%!had!suffered!some!form!of!physical!or!psychological!abuse.2118,2119!One!possible!cause!of! this!discrepancy!may!be!that!survey!respondents!were!asked!to! list! the!methods!used! in! the!preceding!week!as&a&form&of&punishment,!rather!than!for!any!reason,!though!it!is!not!possible!to!confirm!this! hypothesis.! Sommerfelt! suggests! that! although! the! proportions! of! children! experiencing! each!method! of! punishment! were! similar! between! child! domestic! workers! and! other! children,! the!psychological!impact!of!punishment!may!be!greater!for!child!domestic!servants.2120!!









!


Figure.157:.Percentage.of.children.punished.using.various.methods.during.the.preceding.week.(graph),.by.child.domestic.worker.status.and.sex,.2001.



!!Figure.158:.Percentage.of.children.punished.using.various.methods.during.the.preceding.week.(table),.by.child.domestic.worker.status,.urban/rural.status,.and.sex,.2001.



!!

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In!addition! to!physical! violence,! child!domestic!workers! routinely!experience!psychological! abuse! that!deepens! their! subjugation! and! damages! their! psychosocial! health! and! development.2121,2122,2123,2124,2125!The!derogatory!and!pejorative!cultural!understanding!of!the!term!“restavek”!is!itself!a!manifestations!of!psychological!abuse,!as!child!domestic!workers’!identities!are!therefore!defined!by!subservience!and!low!value.2126!Though!the!extent!and!dynamics!of!psychological!violence!against!child!domestic!workers!have!not!been! studied! in!detail,! a!number!of! sources!attest! to! its!prevalence!and!effects,! including! serious!psychosocial! trauma,! intense! feelings!of! inferiority,! incontinence,!and! fear!of!adults,! generally,! and!of!men,! specifically.2127,2128,2129,2130,2131! Child!domestic!workers! surveyed! in! 2001!overwhelmingly! reported!that!they!did!not!feel!part!of!the!household’s!emotional!community.2132!With!few!other!opportunities!to!receive!affection,!affirmation,!and!a!sense!of!belonging,!especially!among!those!who!are!not!in!school,!child! domestic! workers! confront! formidable! risks! to! their! psychological! health,! development,! and!wellbeing.!!Of!critical! importance!to!programs!and!policies!affecting!child!domestic!workers!is!the!high!proportion!of!female!(and,!to!a!lesser!degree,!male)!child!domestic!workers!who!have!been!sexually!abused!by!men!

















!


and!boys!in!host!households,!and!the!high!rate!at!which!sexual!abuse!occurs.2133,2134,2135,2136!A!2006!study!of!households!in!Portàu`Prince!by!Kolbe!and!Hudson!estimated!that!9.6%!of!female!restaveks!had!been!sexually!assaulted! in!the!22!months!preceding!the!survey,!and!that!5.2%!were!sexually!assaulted!each!year.2137! If! adjusted! for! the! amount! of! time! a! female! restavek! spends! in! domestic! servitude,! this!prevalence!estimate!is!higher!than!that!of!the!UN!Special!Rapporteur!on!contemporary!forms!of!slavery,!who!estimated! that!between!7%!and!10.5%!of! female! restaveks! had!ever!been! sexually! assaulted.2138!However,! this! discrepancy! may! be! the! result! of! prevalence! differences! between! Portàu`Prince! and!other! areas.! Overall,! Kolbe! and! Hudson! estimated! that! female! restaveks! in! Portàu`Prince! were! 4.5!times!more! likely! to!have!been!sexually!assaulted!than!girls!who!were!not!restaveks.!Additionally,! the!study! estimated! that! restaveks! comprised! 36.2%!of! all! sexual! assault! victims,! and! that! 68.0%!of! child!victims!of!sexual!assaults!were!restavek!girls.2139!It!has!been!noted!with!regret!that!if!a!female!restavek!becomes!pregnant,!even!as!a!result!of!sexual!assault,!she!will!be!fired!and!pushed!into!the!street,!where!many!such!girls!become!street!children.2140!!In! addition! to! their! risk! of! physical,! psychological,! and! sexual! abuse,! many! child! domestic! workers!confront!extreme!neglect!and!lack!of!commensality!with!other!children!in!host!households.!Despite!the!expectation!that!these!households!will!fulfill!child!domestic!workers’!basic!needs,!such!as!food,!clothing,!shelter,! healthcare,! and! education,! in! practice,! child! domestic! workers! are! often! deprived! of! such!fundamental!rights,!or!have!significantly!less!access!than!other!children!in!the!household.2141,2142,2143,2144!













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Child!domestic!workers!receive!clothes!less!often!than!other!children,!and!may!be!required!to!eat!in!a!different!location!and/or!after!other!household!members.!In!urban!areas,!other!household!children!are!often! provided! with! better! sleeping! facilities! than! child! domestic! workers,! though! the! same! has! not!been!found!to!be!true!in!rural!areas.2145!The!UN!Special!Rapporteur!on!contemporary!forms!of!slavery!noted!in!2009!that!many!restaveks!were!malnourished,!only!provided!with!food!at!school,!and!had!little!or!no!access!to!healthcare.2146!Additionally,!the!2006!State!of!the!World’s!Children!report!stated!that!15!year`old! child! domestic! workers! in! Haiti! were,! on! average,! four! centimeters! shorter! and! 40! pounds!lighter! than! children! of! the! same! age! who! were! not! domestic! servants.2147! Malnutrition! and! lack! of!access!to!healthcare!increase!child!domestic!workers’!risk!of!infectious!and!non`communicable!diseases.!As!a!result,!“(c)hildren!in!domestic!service!frequently!suffer!from!shingles,!typhoid!fever,!gastroenteritis,!parasitic! diseases,! vitamin!A! deficiency,! acute! respiratory! infections,! tuberculosis,!meningitis,!malaria,!conjunctivitis,!urinary!infections,!mycoses,!STDs!and!increasingly!from!AIDS.”2148!!!Lack!of!parental!care,!heavy!workloads,!inadequate!access!to!education!and!support!services,!and!high!rates!of!physical,!psychological!and!sexual!abuse!compel!decision`makers!to!act!urgently!to!reduce!the!risks! faced! by! children! in! domestic! service! and! servitude.! Available! evidence! suggests! that! the!experiences!of!many!child!domestic!workers!are!in!contravention!of!Article!32!of!the!UN!Convention!on!the!Rights!of! the!Child,!which! states! that! a! child’s!work!may!not! interfere!with! their! education!or! be!harmful! to! their! health! or! physical,!mental,! spiritual,!moral! or! social! development.2149! Child! domestic!workers!are!among!the!most!vulnerable!of!Haiti’s!children,!and!their!protection!requires!the!concerted!efforts! of! programmers! and! policy`makers! to! both! reduce! structural! impediments! and! entrenched!vulnerabilities!and!to!promote!the!realization!of!their!rights.!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!2144!UN!Committee!on!the!Rights!of!the!Child,!Consideration!of!reports!submitted!by!state!parties!under!article!44!of!the!Convention:!Haiti,!UN!Doc.!CRC/C/51/Add.7!(2002).!Available!at!http://www.unhcr.org/refworld/docid/3df59ad34.html!






2149!Convention!on!the!Rights!of!the!Child,!G.!A.!Res.!44/25!(1989).!Available!at!http://www2.ohchr.org/english/law/crc.htm!

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B.&Child&labor&migration&to&the&Dominican&Republic&!The! parallel! challenges! of! high! household! poverty! and! limited! economic! opportunity! compel! many!Haitian!children!to!migrate!in!search!of!work!to!support!themselves!and!their!families.!The!World!Bank!has!noted! that!both!domestic! and! international! child!migration! in!Haiti! is! triggered!by! socioeconomic!factors,! local! constraints,! and! lack! of! opportunity! in! children’s! home! communities.2150! Migration! is!perceived! as! a! coping! strategy! to! constrained! labor! markets,! pervasive! household! poverty,! and! an!inadequate!education!system.!!Portàu`Prince!is!the!preferred!destination!for!child!labor!migrants!from!outside!of!the!capital.!However,!to!succeed!in!Portàu`Prince,!young!migrant!workers!require!both!a!degree!of!education!and!a!network!of! contacts! in! the! capital! to! assist! them! in! finding! employment! and!housing.!However,! young!people!face! a! number! of! barriers! to! success! as! economic!migrants! in! Portàu`Prince.! Lack! of! education! is! a!particular!challenge,!especially!for!children!migrating!from!rural!areas!where!educational!attainment!is!typically!lower!than!in!urban!areas.!Educational!attainment!increases!the!probability!of!acceptance!by!a!patron,!disenfranchising!many!young!migrants!from!rural!areas.!However,!while!a!degree!of!education!is!necessary! to! succeed! in! the! capital,! by! itself! it! is! not! sufficient.! Yet! another! challenge! relates! to! the!patrimonial! nature! of!Haiti’s! labor!market,!which!has! led!many! young!people! to! state! that! “who! you!know!is!more! important!than!what!you!know.”2151!Migrants!who!have!relatives!and!family!contacts! in!Portàu`Prince!are!at!a!relative!advantage!as!they!are!able!to!use!these!contact!to!access!housing!and!the!labor!market.!!!The! high! probability! of! finding! work! across! the! border,! dearth! of! available! opportunities! in! Portàu`Prince! and! their! home! communities,! and! the! comparatively! low! opportunity! cost! of! migration! help!explain!why!so!many!young!Haitians!choose!to!migrate!illegally!to!the!Dominican!Republic,!as!does!the!porous! nature! of! Haiti’s! border!with! the!Dominican! Republic! and! the! significant! cost! associated!with!travel!to!other!countries.!In!contrast!to!migration!to!Portàu`Prince,!working!in!the!Dominican!Republic!is!seen!as!“being!available!to!everyone!who!can!make!it!across!the!border.”2152!!!Few!estimates!of!the!number!or!percentage!of!Haitian!children!migrating!to!the!Dominican!Republic!in!search! of! work! are! available.! The! ILO! has! noted! that! trafficking! of! children,! especially! for! labor! and!sexual!exploitation,! is!a!hidden!phenomenon!that!complicates!rigorous!data!collection,!and!has!stated!that!child!trafficking!statistics!should!be!considered!illustrative!of!these!underlying!issues.2153!In!2002,!a!study! by!UNICEF! and! the! International!Organization! for!Migration! estimated! that! between! 2,000! and!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!2150!H.!Lunde,!Young&Haitian&labour&migrants:&Risks&and&opportunities&in&Haiti&and&the&Dominican&Republic,!Fafo!Report!2010:!24!(2010).!Available!at!http://www.fafo.no/pub/rapp/20168/20168.pdf!!




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3,000! children! migrate! to! the! Dominican! Republic! in! search! of! work! each! year.2154,2155,2156,2157! In!contrast,!field!work!by!Smucker,!Pierre,!and!Tardieu!in!2008!estimated!that!3,212!children!migrated!to!the!Dominican!Republic!every!year!from!troubled!urban!neighborhoods!in!Port`au`Prince,!Cap`Haïtien,!Gonaïves,! Saint`Marc,! and!Petit`Gôave!alone! (Figure!159).! These! findings! indicate! that! the!number!of!children! migrating! to! the! Dominican! Republic! from! all! of! Haiti! may! be! far! higher! than! previously!estimated,!especially!given!that!children!in!other!cities!were!more!likely!to!migrate!than!those!in!Port`au`Prince,2158!and!that!those!in!rural!areas!were!more!likely!to!migrate!than!their!urban!peers.2159!!!According!to!UNICEF,! the!Brigade!de!Protection!des!Mineurs! intercepted!1,437!children!attempting!to!cross!into!the!Dominican!Republic!through!Belladere!in!the!eight!months!between!May!and!December!of!2010.2160!Given!that!this!number!is!from!one!crossing!point,!and!covers!only!eight!months,!it!seems!reasonable!to!conclude!that!the!number!of!children!attempting!to!enter!the!Dominican!Republic!to!find!work!following!the!earthquake!was!significantly!higher!than!in!previous!years.!This! increase!is! likely!to!be! due! to! the! relative! lack! of! opportunities! available! to! Haitian! children! following! the! earthquake,!discussed! further!below.! Interestingly,! the!2001!Haiti! Living!Conditions! Survey! found! that! youth!were!more! likely! to! migrate! to! the! Dominican! Republic! than! older! Haitians,! suggesting! that! domestic!economic! opportunities!may! be! less! accessible! to! young! people! in! Haiti,!motivating! their! decision! to!migrate! to! the! Dominican! Republic,! or! that! younger! Haitians! face! fewer! barriers! to! movement! than!adults.2161!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!2154!UN!ESC,!Situation!of!human!rights!in!Haiti,!UN!Doc.!E/CN.4/2006/115!(2006).!Available!at!http://ap.ohchr.org/documents/dpage_e.aspx?m=47!






2160!UNICEF,!Field&diary:&Fighting&child&trafficking&on&Haiti’s&border!(February!2011).!Available!at!http://www.unicef.org/infobycountry/haiti_57675.html!!


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Figure.159:.Child.vulnerability.to.street.life.and.transport.to.the.Dominican.Republic,.by.surveyed.city,.2008.

SITE Children in percent N =

children age 5 to 17 Street children Children to

the DR Deported from DR

Carrefour Feuilles / Fontamara / Martissant 0 1.0 0 309 Solino / Bel-Air 1.0 1.2 0 484 Cité Soleil 1.8 .7 0 272 Delmas / Tabarre 0 1.6 .3 320 Mon Repos / Lamentin 0.7 0.7 0 303 PORT-AU-PRINCE 0.7 1.1 0.1 1688 Cap: Bassin Rodo 1.1 1.1 1.1 186 Cap: Centre Ville 2.4 1.9 0 207 Cap: Petite Anse 1.9 4.4 0 159 CAP HAITIAN 1.8 2.4 0.4 552 Gonaïves 2.9 2.1 0.2 421 Saint-Marc 6.3 2.2 0.9 316 Petit-Goâve .9 3.4 0 235


!!The! 2007! Human! Development! Report! identified! three! factors! that! generally! explain! young! people’s!propensity! to!migrate:!1)! individual! factors,!2)! familial! factors,!and!3)!community! factors.2162!All! three!categories,! discussed! in! the! Haitian! context! below,! can! either! encourage! or! discourage! child! labor!migration.! At! the! individual! level,! young! Haitians’! decision! to! migrate! is! an! investment! in! economic!opportunity.! Due! to! the! low! wages! afforded! to! young! people! within! Haiti,! combined! with! pervasive!poverty! and! the! vulnerability! of! prior! livelihood! strategies,!migration! offers! the! prospect! of! financial!independence!and!self`sufficiency.!This!in!turn!allows!the!youth!to!save!money!for!education,!marriage,!or!simply!a!higher!standard!of!living.!Lunde!notes!that!the!opportunity!cost!of!relocation!is!likely!to!be!lower!for!young!people!than!their!older!peers,!and,!as!such,!migration!offers!Haitian!youth!the!chance!to!maximize!personal!well`being!while!sacrificing!comparatively!little.!She!also!observes!that!the!inverse!is!also! true—increased! opportunity!within!Haiti! is! associated!with! a! lower! propensity! to!migrate! to! the!Dominican! Republic.! For! young! Haitians,! the! relative! and/or! absolute! benefits! derived! from! labor!migration! compel!many! to! accept! the! risks! inherent! in! illegal! cross`border! labor!migration! given! the!inadequacy!of!opportunities!within!Haiti!to!meet!their!needs.2163!!



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The! family! and! household! play! an! important! part! in! some! children’s! decisions! to! migrate! to! the!Dominican!Republic!in!search!of!work.!As!Lunde!notes,!“Young!people!are!often!not!allowed!full!agency!over!decisions!important!to!them,!and!in!addition!need!to!consider!the!preferences!of!other!household!members.”2164!Poverty!is!generally!considered!a!household,!rather!than!purely!individual,!phenomenon.!As!the!primary!motivator!of!child!labor!migration,!the!household’s!need!to!spread!risk!and!vulnerability!through!children’s!employment!drives!many!who!do!not!have!the!education!or!patronage!networks! in!Port`au`Prince!to!cross!the!border.!This!is!especially!true!of!young!boys.2165!Households!may!expect!two!outcomes! from! such!migration:! the! child!may!become! self`sufficient,! freeing! household! resources,! or!the!child!may!send!back!remittances,!providing!the!household!with!an!important!source!of!income.!The!practice!of!young!Haitians!migrating! to! the!Dominican!Republic! is! socially!accepted,!especially! in! rural!areas,! and! may! also! publically! display! the! household’s! social! capital! to! others! in! the! community.!However,!social!acceptance!ends!if!trouble!befalls!the!child.!In!such!cases,!the!child’s!family!is!“met!with!social!sanctions!for!exposing!their!children!to!risk.”2166!!!Community!factors!affecting!the!propensity!of!Haitian!children!to!migrate!in!search!of!work!also!affect!the! opportunity! costs! of!migration.! Young! people! with! access! to! education,! economic! opportunities,!infrastructure!and!leisure!activities,!may!be!less!likely!to!migrate,!as!they!must!sacrifice!these!communal!opportunities! to! find!work.! If,! on! the!other!hand,! children! lack! access! to! these! communal! assets,! the!opportunity!cost!of!migration!will!be! lowered!and!the!anticipated!benefits!of!migration!may!outweigh!the!sacrifices!necessary!to!relocate.!This!may!explain!why!young!Haitians!in!rural!areas!are!more!likely!to!migrate! than! their! urban! counterparts,! as! their! access! to! education,! gainful! employment,! public!infrastructure,!and!leisure!activities!is!lower!than!that!of!children!in!urban!areas.!Additionally,!children!in!communities!that!have!witnessed!significant!rates!of!labor!migration!may!feel!compelled!to!migrate!as!a!rite!of!passage!to!adulthood,!while!those!who!do!not!migrate!may!be!perceived!as!lazy!by!others!in!the!community.2167!!Child!migrants! to! the!Dominican!Republic! face!significant! risks!when!crossing! the!border,!while! in! the!Dominican! Republic,! and,! for! girls,! upon! arrival! home.! However,! remaining! in! Haiti! without! viable!opportunities! also! presents! risks,!which! for! some! young! people! supersede! those! of!migration.! Lunde!found! that! the! beliefs! that! Haiti! had! “nothing! to! offer,”! working! in! the! Dominican! Republic! being!“available! to! everyone,”! young! people’s! lives! being! “out! of! their! control,”! and! “acceptance! of! a! high!level!of!risk!as!a!fact!of!life”!were!pervasive!among!interviewed!young!people.!Her!study!indicated!that!





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prospective! young! migrants! are! well! aware! of! the! risks! involved! with! illegal! migration,! but! that!migration!offered!one!of!very!few!options!for!social!and!economic!mobility.2168!!Illegally! crossing! the! Dominican! border! exposes! young! Haitian! migrants! to! a! variety! of! risks! that!discourage!many!from!attempting!the!journey.!The!crossing!from!Haiti!to!Dominican!sugar!plantations!takes!between!five!and!eight!days.!Migrants!typically!travel!at!night!and!in!difficult!terrain!to!reduce!the!risk!of!capture!by!Dominican!authorities,!and!accidents!are!not!uncommon.!Dominican!guards!patrol!the!border,! often! with! dogs.! If! caught,! illegal! migrants! will! be! detained! and! deported! to! Haiti,! generally!following!the!confiscation!of!property!and!any!money!the!migrant!has!earned.!Many!deported!migrants!describe! abusive! treatment! by! Dominican! border! authorities!while! in! custody,! and! anecdotal! reports!suggest!the!occurrence!of!sexual!abuse!against!migrant!girls!in!detention.!After!the!confiscation!of!their!property!and!money,!some!young!Haitians!have!settled!in!the!border!area!until!an!opportunity!to!return!home!arises,!having!been!unable!to!inform!family!or!friends!of!their!situation.!Criminal!gangs!also!patrol!the!border,!and!many!have!specialized!in!assaulting!and!robbing!young!migrants!attempting!to!cross!the!border.!Migrants!returning!from!the!Dominican!Republic!confront!even!greater!risk!as!they!are!carrying!what!money!they!have!earned.2169!!Prospective!migrant! youth! are! aware! of! the! risks! involved! with! the! border! crossing.! As! a! result,! the!majority!pay!an!experienced!migrant!(a!vyewo)!to!guide!them!across!the!border!and!contact!a!reliable!employer.!Young!labor!migrants!consider!the!use!of!a!vyewo!to!be!a!risk!reduction!measure,!and!many!stress! the! importance! of! a! good! vyewo! to! cross! the! border! successfully! as! these! guides! have! greater!experience!with!the!hazardous!border!crossing!and!contacts!within!the!Dominican!Republic.2170!This! is!especially!true!for!first`time!migrants!who!lack!familiarity!with!the!journey.!According!to! interviewees,!lack!of!a!personal!contact!with!a!vyewo!was!a!limiting!factor!in!cross`border!migration!only!a!few!years!ago.!However,!as!the!number!of!young!people!who!have!crossed!the!border!has!grown,! it! is! reported!that! hiring! a! vyewo! in! border! towns! who! was! previously! unknown! by! the! prospective! migrant! has!become!much!easier!in!recent!years.2171!A!2006!study!by!Ferguson!found!that!vyewo!typically!received!around!US$80!per!child!the!guided!across!the!border,!and!that!Dominican!border!guards!might!receive!US$1.25!`!$3.50!per!child!they!allow!into!the!country.2172!!!Under! the! UN! Protocol,! vyewos! are! considered! child! traffickers.! However,! to! the! children!wishing! to!cross!the!border,!vyewos!reduce!the!risk!of!robbery,!capture,!injury,!and!death.!This!contrast!illustrates!



2170!H.!Lunde,!Young&Haitian&labour&migrants:&Risks&and&opportunities&in&Haiti&and&the&Dominican&Republic,!Fafo!Report!2010:!24!(2010).!Available!at!http://www.fafo.no/pub/rapp/20168/20168.pdf!


2172!J.!Ferguson,!“The!Haitian!minority!in!the!Dominican!Republic,”!in!T.!Lester!(ed),!Intra5Caribbean&migration&and&

the&conflict&nexus!(Ottawa:!Human!Rights!Interest,!2006).!

&



the! complexity! involved! in! assessing! child! migrants’! vulnerability.! Haitian! children! crossing! the!Dominican!border!are!compelled!to!migrate!by!individual,!familial,!and!communal!factors.!As!such,!it!is!often!children!themselves!who!decide!to!migrate!given!the!vulnerability!of!their!situation!in!Haiti,!rather!than!through!abduction!or!forceful!recruitment.!Lunde!has!noted!that!in!Haiti,!as!elsewhere,!“there!are!grey! zones! between! cross`border! migration! and! the! more! legally! challenging! phenomena! of! human!smuggling!and!trafficking.”2173!As!described!in!Section!4B.&Child&trafficking,!the!UN!Protocol!to!Prevent,!Suppress! and! Punish! Trafficking! in! Persons,! Especially! Women! and! Children,! the! “recruitment,!transportation,! transfer,! harbouring! or! receipt! of! a! child! for! the! purpose! of! exploitation! shall! be!considered! ‘trafficking! in! persons’! even! if! this! does! not! involve! any! of! the! means! set! forth! in! the!definition.”2174!Accordingly,!UNICEF!and!the!International!Labour!Organization!have!noted!that!the!use!of! violence! or! fraud! is! not! necessary! for! the! practice! to! be! considered! trafficking! in! the! case! of!children.2175!The!application!of!this!definition!to!the!distinction!between!migration!and!child!trafficking!is!complicated!by!questions!of!agency!and!method.!!!While! travelling! with! a! vyewo! reduces! the! risk! of! detention! or! robbery! for! migrating! young! people,!Lunde!found!that!vyewos!would!occasionally!take!migrants’!money!and!abandon!them!along!the!route.!Interviewed! youth! considered! this! possibility! a! calculated! risk,! though! many! in! migrants’! home!communities!know!of!cases!where! it!had!occurred.! It!was!found!that!“the!risk!of!being!dropped!along!the! route! is! substantially! decreased! when! travelling! with! a! vyewo! belonging! to! the! migrant’s! social!network,! where! obligations! between! groups! and! families! and! fear! of! social! sanctions! regulate! the!incentive! for!exploitation.”!The!participation!of! the! family! in!a! child’s!decision! to!migrate! in! search!of!work!may! therefore! reduce! the! risk! faced!by! the!migrant,! as! greater! commitment! by! the! family!may!yield!greater!protection.2176!!Once!in!the!Dominican!Republic,!migrant!Haitian!workers!are!at!the!mercy!of!their!employers.!!Due!to!their!illegal!status,!the!vast!majority!of!migrants!have!no!labor!rights,!legal!protections,!or!social!safety!nets.!The!work!performed!by!Haitian!migrants!is!usually!unskilled,!heavy!manual!labor,!with!boys!generally!employed!in!construction!and!agriculture,!and!girls!as!maids!or!other!house!staff.2177,2178!These!jobs! are! unattractive! to! Dominicans,! and! the! most! difficult! and! dangerous! jobs! in! construction! and!agriculture! are! performed! almost! exclusively! by! Haitians.! Dominican! employers! benefit! from! the!availability! and! vulnerability! of!Haitian!migrant!workers,! offering! lower!wages! than! those! afforded! to!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!2173!H.!Lunde,!Young&Haitian&labour&migrants:&Risks&and&opportunities&in&Haiti&and&the&Dominican&Republic,!Fafo!Report!2010:!24!(2010).!Available!at!http://www.fafo.no/pub/rapp/20168/20168.pdf!!





2178!J.!Ferguson,!“The!Haitian!minority!in!the!Dominican!Republic,”!in!T.!Lester!(ed),!Intra5Caribbean&migration&and&

the&conflict&nexus!(Ottawa:!Human!Rights!Interest,!2006).!

!


Dominicans! performing! the! same! tasks,! providing! no! employment! protection,! demanding! excessive!work!hours,!and!sometimes!refusing!to!pay!Haitian!workers!at!the!end!of!the!contract.2179!Lacking!both!bargaining! power! and! protections,!migrants! are! vulnerable! to! victimization! by! their! employers.! They!work!for!longer!hours!and!less!pay!than!their!Dominican!counterparts,!and!in!addition!to!being!refused!payment! at! the! end! of! their! service,! they! may! be! harassed,! abused,! humiliated,! and/or! socially!segregated.! Opposition! may! lead! to! immediate! dismissal! or! presentation! to! the! authorities! for!deportation.! However,! it! has! been! noted! that! a! successful! return! to! Haiti! offsets! a! degree! of! the!indignity!born!by! labor!migrants,!as!the!injection!of!household! income!increases!the!social!standing!of!the!migrant!and!their!family.2180!!Young!female!migrants!face!greater!risks!than!their!male!counterparts!in!the!Dominican!Republic.!This!is!in!part!due!to!the!fact!that!girls!are!generally!employed!alone!in!Dominican!households!as!maids,!with!no!connection!to!a!Haitian!peer!group.!The!hidden!nature!of! their!work!also!exposes! them!to!greater!risk! of! abuse,! including! sexual! violence.!Additionally,! and! in! contrast! to! young!men,!Haitian! girls!who!migrate! to! the! Dominican! Republic! in! search! of!work! are! stigmatized! in! Haiti.! There! is! a!widely! held!perception! that,! even! if! it! was! not! their! intention,! girls! who!migrate! to! the! Dominican! Republic! will!become!involved!in!prostitution,!bringing!stigma!to!both!the!girls!and!their!families!in!Haiti.!Lunde!notes!that!this!perception!may!have!been!strengthened!by!anti`trafficking!campaigns!in!Haiti!that!emphasized!migration! to! the! Dominican! Republic! as! a! route! into! the! sex! trade.!While! interviews! with! migration!organizations! in! Haiti! and! the! Dominican! Republic! revealed! that! many! Haitian! girls! are! involved! in!prostitution!on!Dominican!cities,!the!extent!is!unknown,!and!Lunde!has!suggested!that!it!is!likely!to!be!a!small!proportion!of! those!who!were! forced! to!have! transactional! sex! in! the! journey! to!or!once! in! the!Dominican! Republic.2181! Both! the! increased! risks! faced! by!migrant! Haitian! girls! and! the! social! stigma!confronted!by!them!and!their!families!mean!that!the!“costs”!of!migration!are!much!greater!for!girls!than!for! boys.! As! a! result,! boys! comprise! the! overwhelming! majority! of! labor! migrants! to! the! Dominican!Republic,!despite!a!high!demand!for!girls!in!the!domestic!and!service!sectors.2182!!Despite!the!significant!risks!confronting!young!Haitian!labor!migrants,!the!potential!rewards!of!working!in! the! Dominican! Republic! compel! many! to! cross! the! border! in! search! of! work.! Those! migrants!succeeding!in!the!Dominican!Republic!return!to!Haiti!with! income,!clothes,!and!livestock,!and!increase!the! social! status! of! themselves! and! their! families.! Income! earned! in! the! Dominican! Republic! allows!migrants! to! support! their! families,! as!well! as! providing! an! investment! in! their! own! future! endeavors,!





&



including!education!and!marriage.2183! It! is!unlikely! that! the!motivation! to!seek!work! in! the!Dominican!Republic!will!be!curtailed!until!similar!opportunities!are!available!to!young!people!in!Haiti;!an!important!consideration!as!the!country!continues!rebuilding!from!the!January!2010!earthquake.!!


!


References&!"Building!a!safer!Haiti,"!New&York&Times!(Editorial,!September!19,!2011).!Available!at!http://www.nytimes.com/2011/09/20/opinion/buildingà`safer`haiti.html!

A.!Desrosiers!and!S.!St!Fleurose,!"Treating!Haitian!patients:!key!cultural!aspects,"!American&Journal&of&

Psychotherapy!56/4!(2002),!pp.!508`521.!!

A.!J.!Gage,!"Women's!experience!of!intimate!partner!violence!in!Haiti,"!Social&Science&&&Medicine!61/2!(2005),!pp.!343`364.!!

A.!M.!Gomez,!I.!S.!Speizer,!and!H.!Beauvais,!"Sexual!violence!and!reproductive!health!among!youth!in!Portàu`Prince,!Haiti,"!Journal&of&Adolescent&Health!44!(2000),!pp.!508`510.!!

A.!R.!Kolbe!and!R.!A.!Hutson,!"Human!rights!abuse!and!other!criminal!violations!in!Portàu`Prince,!Haiti:!a!random!survey!of!households,"!The&Lancet!368!(2006),!pp.!864`873.!!

A.!R.!Kolbe,!R.!Muggah,!R.!A.!Hutson,!et!al.,!Assessing&needs&after&the&quake:&Preliminary&findings&from&a&

randomized&survey&of&Port5au5Prince&households,!University!of!Michigan/Small!Arms!Survey!(April!2010).!Available!at!http://www.comunidadesegura.org/files/Results%20of%20a%20Random%20Survey%20of%20Haitian%20Households.doc!

A.!R.!Tuite,!J.!Tien,!M.!Eisenberg,!et!al.,!"Cholera!epidemic!in!Haiti,!2010:!Using!a!transmission!model!to!explain!spatial!spread!of!disease!and!identify!optimal!control!interventions,"!Annals&of&Internal&Medicine!154!(2011),!pp.!593`601.!!

ALNAP,!Haiti&earthquake&response:&Context&analysis!(July!2010).!Available!at!http://www.alnap.org/pool/files/haiti`contextànalysis`final.pdf!

Amnesty!International,!Don't&turn&your&back&on&girls:&Sexual&violence&against&girls&in&Haiti!(2008).!Available!at!http://www.amnesty.org/en/library/asset/AMR36/004/2008/en/f8487127`b1a5`11dd`86b0`2b2f60629879/amr360042008eng.pdf!

Amnesty!International,!Haiti:&After&the&quake,&Initial&Mission&Findings!(March!2010).!Available!at!http://www.amnesty.org/en/library/asset/AMR36/004/2010/en/d12e3cdc`2103`40b8àf57`1412dcf3d413/amr360042010en.pdf!

Amnesty!International,!Overcoming&poverty&and&abuse:&Protecting&girls&in&domestic&service&in&Haiti!(November!2009).!Available!at!http://www.amnesty.org/en/library/info/AMR36/004/2009!

Amnesty!International,!Safe&schools:&Every&girl's&right&(March!2008).!Available!at!http://www.amnesty.org/en/library/info/ACT77/001/2008!

B.!Hadjadj,!Education&for&all&in&Haiti&over&the&last&20&years:&Assessment&and&perspectives,!UNESCO!Education!for!all!in!the!caribbean:!Assessment!2000!monograph!series!No.!18!(2000).!Available!at!http://unesdoc.unesco.org/images/0013/001363/136393e.pdf!

!References&


CDC,!CDC&summary&of&initial&rapid&assessment&conducted&by&UN&OCHA&in&Haiti!(February!2010).!!

Center!for!Human!Rights!and!Global!Justice,!Sexual&violence&in&Haiti's&IDP&camps:&Results&of&a&household&

study,!New!York!University!School!of!Law!(March!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Child%20Protection/studies%20reseaches%20evaluation%20books/Haiti%20Sexual%20Violence%20March%202011.pdf!

CNSA,!Rapid&post5earthquake&emergency&food&security&assessment:&Haiti!(March!2010).!Available!at!http://documents.wfp.org/stellent/groups/public/documents/ena/wfp221395.pdf!

Convention!concerning!Minimum!Age!for!Admission!to!Employment!(C138),!ILO!Convention!C138!(1973).!Available!at!http://www.ilo.org/ilolex/cgi`lex/convde.pl?C138!

Convention!on!the!Rights!of!the!Child,!G.!A.!Res.!44/25!(1989).!Available!at!http://www2.ohchr.org/english/law/crc.htm!!

Cultural!Consultation!Service,!Mental&health&in&Haiti:&A&literature&review!(February!2010).!Available!at!http://www.state.nj.us/humanservices/dmhs/disaster/MH_in_Haiti%20_Literature_Review.pdf!

D.!E.!Bloom,!D.!Canning,!and!J.!Sevilla,!The&demographic&dividend:&A&new&perspective&on&the&economic&


D.!L.!Chao,!M.!E.!Halloran,!and!I.!Longini,!"Vaccination!strategies!for!epidemic!cholera!in!Haiti!with!implications!for!the!developing!world,"!Proceedings&of&the&National&Academy&of&Sciences&USA!108/17!(2011),!pp.!7081`7085.!!

D.!Sontag,!"In!Haiti,!capital!braces!for!cholera!outbreak,"!New&York&Times!(October!24,!2010).!Available!at!http://www.nytimes.com/2010/10/25/world/americas/25haiti.html?_r=1&hp!

D.!Verner,!Labor&markets&in&rural&and&urban&Haiti:&Based&on&the&first&household&survey&for&Haiti,!World!Bank!Sustainable!Development!Division!(March!2008).!Available!at!http://go.worldbank.org/MYDYDJHFS0!

D.!Verner,!Making&poor&Haitians&count:&Poverty&in&rural&and&urban&Haiti&based&on&the&first&household&

survey&for&Haiti,!World!Bank!Sustainable!Development!Division!(March!2008).!Available!at!http://go.worldbank.org/AE6TJ7EPY0!

D.!W.!Fitzgerald,!F.!Behets,!A.!Caliendo!A,!et!al.,!"Economic!hardship!and!sexually!transmitted!diseases!in!Haiti's!rural!Artibonite!Valley,"!American&Journal&of&Tropical&Medicine&and&Hygiene!62/4!(2000),!pp.!496`501.!!

D.!Walton,!A.!Suri,!and!P.!Farmer,!"Cholera!in!Haiti:!Fully!integrating!prevention!and!care,"!Annals&of&Internal&Medicine!154/9!(2011),!pp.!635`637.!!

Defend.ht,!“National&fund&for&education&is&not&operational”&says&Haiti&Education&Minister,!Defend.ht!(26!November!2011).!Available!at!http://www.defend.ht/politics/articles/executive/2075`qnational`fund`forèducationìs`notòperationalq`says`haitièducation`minister!

!


Demographic!and!Health!Surveys,!Measure&DHS&STATcompiler.!Available!at!http://www.statcompiler.com/!

DevInfo,!MDG&database&2010:&Haiti.!Available!at!http://www.devinfo.info/mdginfo2010/!

Droits!et!Democratie/GRAMIR,!The&human&right&to&food&in&Haiti:&Report&of&an&international&fact5finding&

mission&(2008).!Available!at!http://www.dd`rd.ca/site/publications/index.php?id=2316&subsection=catalogue!

E.!Lacroi,!Anticipating&the&future:&Children&and&young&people's&voices&in&Haiti's&post5disaster&needs&assessment,!Plan!International!(March!2010).!Available!at!http://plan`international.org/files/global/haiti`pdna`report.pdf!

F.!Ponsar,!N.!Ford,!H.!M.!Van,!et!al.,!"Mortality,!violence!and!access!to!care!in!two!districts!of!Port`au`Prince,!Haiti,"!Conflict&and&Health!3/4!(2009).!!

F.!W.!Anderson,!S.!U.!Morton,!S.!Naik,!and!B.!Gebrian,!"Maternal!mortality!and!consequences!on!infant!and!child!survival!in!rural!Haiti,"!Journal&of&Maternal&and&Child&Health!11/4!(2007),!pp.!395`401.!!

Family!Health!International!(FHI),!The&situation&of&orphans&in&Haiti:&A&summary&assessment:&A&

preliminary&assessment&of&orphans&and&vulnerable&children&with&a&focus&on&children&affected&by&HIV/AIDS!(2001).!Available!at!http://dspace.cigilibrary.org/jspui/handle/123456789/8649?mode=full!

FAO,!The&state&of&food&insecurity&in&the&world&2001!(2001).!Available!at!http://www.fao.org/docrep/003/y1500e/y1500e00.htm!

G.!Maynard`Tucker,!"Haiti:!Unions,!fertility!and!the!quest!for!survival,"!Social&Science&&&Medicine!43/9!(1996),!pp.!1379`1387.!!

G.!Menezes,!Warning&of&the&dangers&of&child&trafficking&in&Haiti,!UNICEF!(23!March!2011).!Available!at!http://www.unicef.org/infobycountry/haiti_58029.html!

G.!Nicolas,!B.!Schwartz,!and!E.!Pierre,!"Weathering!the!storm!like!bamboo:!The!strengths!of!Haitians!in!coping!with!natural!disasters,"!in!A.!Kalayjian!and!D.!Eugene!(eds),!Mass&trauma&and&emotional&healing&

around&the&world!(Santa!Barbara:!Praeger,!2009).!!

G.!Previlon,!Community&youth&mapping&report,!IDEJEN!&!USAID!(August!2004).!Available!at!http://www.equip123.net/docs/e3`CommunityYouthMappingReportHaiti.pdf!

G.!R.!Smucker!and!G.!F.!Murray,!The&uses&of&children:&A&study&of&trafficking&in&Haitian&children,!USAID/Haiti!Mission!(December!2004).!Available!at!http://pdf.usaid.gov/pdf_docs/PNADF061.pdf!

G.!R.!Smucker,!Y.!F.!Pierre,!and!J.!F.!Tardieu,!Lost&childhoods&in&Haiti:&Quantifying&child&trafficking,&restavèks,&&&victims&of&violence,!Pan!American!Development!Foundation!Protecting!Human!Rights!Project!(November!2009).!Available!at!http://www.crin.org/docs/Haiti_lost_childhoods.pdf!

G.!Thompson,!"After!Haiti!quake,!the!chaos!of!U.S.!adoptions,"!New&York&Times!(August!3,!2011).!Available!at!http://www.nytimes.com/2010/08/04/world/americas/04adoption.html?pagewanted=all!

!References&


Gallup!Inc.,!Gallup&worldview&database:&Haiti.!Available!at!https://worldview.gallup.com/default.aspx!

Global!Education!Cluster,!Global&education&cluster&update:&January&5&March&2011,!Global!Education!Cluster!(2011).!Available!at!http://oneresponse.info/GlobalClusters/Education/publicdocuments/Education%20Cluster%20Update_January_March_2011_FINAL.pdf!

Global!Health!Council,!Haiti&and&HIV&after&the&earthquake!(March!2010).!Available!at!http://www.globalhealth.org!

Global!Initiative!to!End!All!Corporal!Punishment!of!Children,!Haiti&country&report!(February!2009).!Available!at!http://www.endcorporalpunishment.org/!

Global!Relief!Technologies,!Haitian&field&assessments:&US&Agency&for&International&Development&weekly&

data&analysis&for&the&week&of&June&14,&2010!(June!2010).!!

Government!of!Haiti,!2009&national&policy&framework&for&an&integrated&approach&to&early&childhood&

development!(January!2009).!!

Government!of!Haiti,!Enquête&mortalité,&morbidité&et&utilisation&des&services&(EMMUS&IV)&200552006!(January!2007).!Available!at!http://www.measuredhs.com/pubs/pdf/FR192/FR192.pdf!

Government!of!Haiti,!Haiti&earthquake&PDNA:&Assessment&of&damage,&losses,&general&and&sectoral&needs!(March!2010).!Available!at!http://siteresources.worldbank.org/INTLAC/Resources/PDNA_Haiti`2010_Working_Document_EN.pdf!

Government!of!Haiti,!Interim&cooperation&framework&200452006:&Summary&report!(2004).!Available!at!http://haiticci.undg.org/uploads/ReportVersion8%20Eng%20FINAL%20Low%20Res.pdf!

Government!of!Haiti,!Rapport&de&situation&nationale&à&l'intention&de&l'UNGASS:&Periode&Janvier&20085Decembre&2009&(March!2010).!Available!at!http://www.unaids.org/en/dataanalysis/monitoringcountryprogress/2010progressreportssubmittedbycountries/haiti_2010_country_progress_report_fr.pdf!

Government!of!Haiti/ACF,!Strategie&de&desengagement:&Water&trucking!(March!29,!2011).!Available!at!http://www.dinepa.gouv.ht/wash_cluster/index.php?option=com_rokdownloads&view=file&task=download&id=1492%3A201103desengagementwt`dinepa`acfstrategievf&Itemid=67!

Guidelines!for!the!Alternative!Care!of!Children,!G.!A.!Res.!64/142!(2010).!Available!at!http://www.unicef.org/protection/alternative_care_Guidelines`English.pdf!

H.!D.!Nielsen,!Moving&towards&free&primary&education:&Policy&issues&and&implementation&challenges&5&A&

state&of&the&art&review,!UNICEF!social!and!economic!policy!working!paper!(2009).!Available!at!http://www.unicef.org/socialpolicy/index_52077.html!

H.!Lunde,!Haiti&youth&survey&2009&5&Volume&I:&Tabulation&report,!Fafo!report!2009/53!(2009).!Available!at!http://www.fafo.no/pub/rapp/20143/20143.pdf!

H.!Lunde,!Young&Haitian&labour&migrants:&Risks&and&opportunities&in&Haiti&and&the&Dominican&Republic,!

!


Fafo!Report!2010/24!(2010).!Available!at!http://www.fafo.no/pub/rapp/20168/20168.pdf!

H.!Lunde,!Youth&and&education&in&Haiti:&Disincentives,&vulnerabilities&and&constraints,!Fafo!paper!2008/26!(2008).!Available!at!http://www.fafo.no/pub/rapp/10070/10070.pdf!

H.!Perry,!A.!Ross,!and!F.!Ferdinand,!"Cause!of!under`five!mortality!in!rural!Haiti:!Findings!from!the!Hopital!Albert!Schweitzer!service!area,"!Revista&Panamericana&de&Salud&Pública!18!(2005),!pp.!178`186.!!

Hague!Conference!on!Private!International!Law,!Status:&Convention&of&29&May&1993&on&protection&of&

children&and&co5operation&in&respect&of&intercountry&adoption!(2011).!Available!at!http://www.hcch.net/index_en.php?act=conventions.status&cid=69!

Haiti!CCCM!Cluster,!Registration&of&internally&displaced&populations&affected&by&the&earthquake&in&Haiti!(December!2010).!Available!at!http://www.eshelter`cccmhaiti.info/pdf/phase_1_registration_final_report_dec_21.pdf!

Haiti!CCCM!Cluster,!Registration&update:&Phase&2!(June!2011).!Available!at!http://www.eshelter`cccmhaiti.info/pdf/REGISTRATION_UPDATE_Phase_2_Mid_Year_Report_June_2011ENGLISH_FINAL%20_Revised.pdf!

Haiti!Child!Protection!Sub`Cluster,!Child&protection&sub5cluster&meeting&minutes:&28&July&2011!(July!2011).!Available!at!http://translate.google.com/translate?sl=auto&tl=en&js=n&prev=_t&hl=en&ie=UTF`8&layout=2&eotf=1&u=http%3A%2F%2Fhaiti.humanitarianresponse.info%2FPortals%2F0%2FChild%2520Protection%2FMinutes%2FCPSC_Meeting_Sept22.pdf!

Haiti!Education!Cluster,&Education&cluster&bulletin:&18&February&2010!(February!2010).!Available!at!http://oneresponse.info/Disasters/Haiti/Education/Documents/ECU!English.docx!

Haiti!Education!Cluster,!Education&cluster&bulletin:&8&August&2011!(August!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/reports/Aout%202011/Education_Cluster_SitRep_080811.pdf!

Haiti!Education!Cluster,!Education&cluster&information&bulletin:&24&September&2011!(September!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/news/Edu_Cluster_info_bulletin_23_sept_eng.pdf!

Haiti!Education!Cluster,!Education&cluster&rapid&joint&needs&assessment&(RJNA):&RJNA&final&report!(March!2010).!Available!at!http://oneresponse.info/Disasters/Haiti/Education/Documents/RJNA%20Report%20ENGLISH.docx!

Haiti!Education!Cluster,!Education&cluster&situation&report:&11&July&2011!(July!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/reports/juillet%202011/Education_Cluster_SitRep_11072011.pdf!

Haiti!Education!Cluster,!Education&cluster&situation&report:&14&December&2010!(December!2010).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/reports/Education_Cluster_SitR

!References&


ep_14_12_2010.pdf!

Haiti!Education!Cluster,!Education&cluster&situation&report:&8&August&2011!(August!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/reports/Aout%202011/Education_Cluster_SitRep_080811.pdf!

Haiti!Education!Cluster,!Education&cluster:&Inputs&for&OCHA&humanitarian&bulletin!(March!2011).!Available!at!http://haiti.humanitarianresponse.info/Portals/0/Education%20Cluster/reports/Education_Cluster_SitRep_Inputs_09032011.pdf!

Haiti!Health!Cluster,!Health&cluster&bulletin&23:&Cholera&and&post5earthquake&response&in&Haiti&(April!2011).!Available!at!http://new.paho.org/disasters/index.php?option=com_docman&task=doc_download&gid=1750!

Haiti!Health!Cluster,!Health&cluster&bulletin&27:&Cholera&and&post5earthquake&response&in&Haiti&(August!2011).!Available!at!http://new.paho.org/disasters/index.php?option=com_docman&task=doc_download&gid=1850!

Haiti!Nutrition!Cluster,!Nutrition&cluster&update:&Issue&3!(October!2011).!Available!at!http://haiti.humanitarianresponse.info/LinkClick.aspx?link=English+Nutrition+cluster+update+issue+3.pdf&tabid=80&mid=1631!

Haiti!Shelter!Cluster,!Shelter&cluster&needs&and&gaps&analysis!(March!2011).!Available!at!https://sites.google.com/site/shelterhaiti2010/files/SHELTER_NEED_ANALYSIS_march_2011_final3.pdf?attredirects=0!

Haiti!Shelter!Cluster,!Shelter&cluster&shelter&completion&update!(August!2011).!Available!at!https://sites.google.com/site/shelterhaiti2010/files/110831Summaryreportbycommune.pdf?attredirects=0!

Haiti!WASH!Cluster,!Enquete&WASH&dans&les&Sites&d'hebergement&temporaire!(May!2011).!Available!at!http://www.dinepa.gouv.ht/wash_cluster/index.php?option=com_rokdownloads&view=file&Itemid=57&id=1468:110616ènquete`wash`site`hebergement`temporaire!

Haitian!Ministry!of!Education,!Youth!and!Sports,!The&problem&of&over5age&students&in&the&Haitian&

education&system:&An&overview.!UNESCO!Education!for!all!in!the!Carribbean:!Assessment!2000!monograph!series!18!(2000).!Available!at!http://unesdoc.unesco.org/images/0013/001364/136433e.pdf!

Haitian!Ministry!of!Social!Affairs!and!Labor,!Response&to&the&United&Nations&Secretary5General's&study&on&violence&against&children&questionnaire&to&governments!(March!9,!2005).!Available!at!http://www2.ohchr.org/english/bodies/CRC/docs/study/responses/Haiti.pdf!

Haitian!National!Commission!on!the!Fight!Against!Drugs,!Drug&prevalence&survey&of&secondary&school&students&in&Haiti,&2005!(August!2007).!Available!at!http://www.cicad.oas.org/oid/caribbean/2007/HAITI%20SCHOOL%20SURVEY.pdf!

HaitiLibre,!"Martelly!working!on!a!fund!project!for!street!children,"!HaitiLibre!(July!6,!2011).!Available!at!http://www.haitilibre.com/en/news`3116`haiti`social`martelly`workingònà`fund`project`for`street`

!


children.html!

Handicap!International,!18&months&of&action&in&Haiti!(July!2011).!Available!at!http://www.handicapìnternational.us/fileadmin/files/documents/July_2011_Haiti_18_mo_Sitrep.pdf!

ICRC,!Inter5agency&guiding&principles&on&unaccompanied&and&separated&children!(January!2004).!Available!at!http://www.ecdgroup.com/docs/lib_004784237.pdf!

ICRC,!Report&of&the&third&workshop&on&protection&for&human&rights&and&humanitarian&organizations:&

Doing&something&about&it&and&doing&it&well,!18`20!January!1999!(January!2000).!!

IFRC,!Haiti&earthquake:&Operations&update&No.&1!(January!2010).!Available!at!http://www.ifrc.org/docs/appeals/10/MDRHT00801.pdf!

IFRC,!Haiti&recovery&assessment:&Volume&1&5&Synthesis&report!(March!2010).!Available!at!http://haiti.humanitarianresponse.info/LinkClick.aspx?fileticket=jNS41RGePVg%3d&tabid=149&mid=1043!

IFRC,!Haiti:&Earthquake&three&month&progress&report!(April!2010).!Available!at!http://www.ifrc.org/docs/appeals/10/MDRHT00814.pdf!

ILO,!Unbearable&to&the&human&heart:&Child&trafficking&and&action&to&eliminate&it,!International!Labour!Office!(2002).!Available!at!http://www.unicef.org/violencestudy/pdf/2002_traff_unbearable_en.pdf!

IMF,!Haiti:&Poverty&reduction&strategy&paper,!IMF!country!report!No.!09/290!(2009).!Available!at!http://www.imf.org/external/pubs/ft/scr/2009/cr09290.pdf!

Institut!Haitien!de!l'Enfance,!HIV/AIDS&in&Haiti:&Key&findings&of&the&mortality,&morbidity,&and&utilization&of&


Institute!for!Democracy!and!Electoral!Assistance,!Voter&turnout&database:&Haiti!(2011).!Available!at!http://www.idea.int/vt/country_view.cfm?CountryCode=HT!

Institute!for!Justice!and!Democracy!in!Haiti,!Our&bodies&are&still&trembling:&Haitian&women's&fight&against&

rape!(July!2010).!Available!at!http://ijdh.org/wordpress/wp`content/uploads/2010/07/Haiti`GBV`Report`Final`Compressed.pdf!

Institute!for!Justice!and!Democracy!in!Haiti,!Sylvio&Cator&stadium&and&Camp&Django&–&the&Government&of&

Haiti’s&continuing&campaign&to&close&IDP&camps&without&respecting&the&human&rights&of&displaced&

communities!(August!9,!2011).!Available!at!http://ijdh.org/archives/20551!

Institute!for!Reproductive!Health,!Awareness&project:&Haiti&country&report,&200552007,!Georgetown!University!(January!2008).!Available!at!http://www.k4health.org/system/files/Haiti%20Country%20Report%202005`2007.pdf!

Inter!American!Development!Bank,!IDB&makes&$35&million&grant&for&Haiti's&electricity&sector&(July!2011).!Available!at!http://www.iadb.org/en/news/news`releases/2011`07`26/support`forènergy`reformìn`

!References&


haiti,9475.html!

IOM,!Displacement&tracking&matrix:&Summary&of&IDP&situation,!Haiti!CCCM!Cluster!(June!2010).!

IOM,!Displacement&tracking&matrix:&V2.0&update,!Haiti!CCCM!Cluster!(September!2011).!Available!at!http://www.cccmhaiti.info/pdf/DTM_V2_Report_September_English.pdf!

IOM,!Population&in&camps&housing&Haitians&left&homeless&by&the&2010&earthquake&drops&below&600,000,!International!Organization!for!Migration!(August!2011).!Available!at!http://www.iomhaiti.com/ft/page.php?id=53!

IOM,!Registration,!International!Organization!for!Migration!(December!2010).!Available!at!http://www.iomhaiti.com/ft/pdf/Brochure.CCCM.Registration.Dec.10.pdf!

J.!C.!Bernat,!"Children!and!the!politics!of!violence!in!Haitian!context:!Statist!violence,!scarcity!and!street!child!agency!in!Portàu`Prince,"!Critique&of&Anthropology!19/2!(1999),!pp.!121`138.!!

J.!C.!Kovats`Bernat,!"Anti`Gang,!arimaj,!and!the!war!on!street!children,"!Peace&Review!12/3!(2000),!pp.!415`421.!!

J.!C.!Kovats`Bernat,!Sleeping&rough&in&Port5au5Prince:&An&ethnography&of&street&children&and&violence&in&Haiti!(Gainesville:!University!Press!of!Florida,!2006).!!

J.!Coreil!and!E.!Genece,!"Adoption!of!oral!rehydration!therapy!among!Haitian!mothers,"!Social&Science&&&Medicine!27/1!(1988),!pp.!87`96.!!

J.!Coreil,!"Allocation!of!family!resources!for!health!care!in!rural!Haiti,"!Social&Science&and&Medicine!17/11!(1983),!pp.!709`719.!!

J.!Coreil,!A.!Augustin,!N.!A.!Halsey,!and!E.!Holt,!"Social!and!psychological!costs!of!preventive!child!health!services!in!Haiti,"!Social&Science&and&Medicine!38/2!(1994),!pp.!231`238.!!

J.!Dayan,!“Haiti,!History,!and!the!Gods,”!in!G.!Prakash!(ed.),!After&Colonialism:&Imperial&Histories&and&

Precolonial&Displacements!(Princeton:!Princeton!University!Press,!2001).!

J.!Ferguson,!"The!Haitian!minority!in!the!Dominican!Republic,"!in!T.!Lester!(ed),!Intra5Caribbean&migration&and&the&conflict&nexus!(Ottawa:!Human!Rights!Interest,!2006).!!

J.!Francis,!A.!Reed,!F.!Yohannes,!et!al.,!"Screening!for!tuberculosis!among!orphans!in!a!developing!country,"!American&Journal&of&Preventive&Medicine!22/2!(2002),!pp.!117`119.!!

J.!Juste,!Haiti:&Digicel&CEO&wants&to&know&where&the&education&money,!Defend.ht!(6!January!2012).!Available!at!http://www.defend.ht/money/articles/business/2398`haiti`digicel`ceo`wants`to`know`whereìs`theèducation`money!

J.!M.!Dash,!Culture&and&customs&of&Haiti!(Westport,!CT:!Greenwood!Press,!2001).!!

J.!Moncrieffe,!"When!labels!stigmatize:!Encounters!with!'street!children'!and!'restavecs'!in!Haiti,"!in!J.!Moncrief!and!R.!Eyben!(eds),!The&power&of&labelling:&How&people&are&categorized&and&why&it&matters!

!


(London:!Earthscan,!2007).!!

J.!R.!Andrews!and!S.!Basu,!"Transmission!dynamics!and!control!of!cholera!in!Haiti:!an!epidemic!model,"!The&Lancet!377!(2011),!pp.!1248`1255.!!

J.!Salmi,!"Equality!and!quality!in!private!education:!The!Haitian!paradox,"!Compare:&A&Journal&of&

Comparative&Education!30/2!(2000),!pp.!163`178.!!

K.!Calvin,!Lighting&the&future&for&Haiti's&women,!UN!Foundation!(January!2011).!Available!at!http://www.unfoundation.org/who`weàre/impact/ourìmpact/empowering`women`girls/lighting`the`future.html!

K.!Tong!and!F.!Gaillardin,!Adolescent&sexual&and&reproductive&health&assessment&mission&to&PLAN,&Haiti!(July!2010).!!

L.!Bengtsson,!X.!Lu,!R.!Garfield,!et!al.,!Internal&population&displacement&in&Haiti:&Preliminary&analyses&of&

movement&patterns&of&Digicel&mobile&phones!(May!2010).!!

L.!Ivers,!A.!Schiff,!D.!Jones,!et!al.,!"Assessment!and!analysis!of!Haitian!HADR!data"!(presentation!to!the!Haiti!Assessments!Working!Group,!April!27!2010).!!

L.!M.!Chatters,!J.!R.!Taylor,!J.!S.!Jackson,!and!K.!D.!Lincoln,!"Religious!coping!among!African!Americans,!Caribbean!blacks!and!non`Hispanic!whites,"!Journal&of&Community&Psychology!36/3!(2008),!pp.!371`386.!!

L.!Wolff,!Education&in&Haiti:&The&way&forward,!Partnership!for!Educational!Revitalization!in!the!Americas!(PREAL)!(September!2008).!Available!at!http://www.thedialogue.org/PublicationFiles/Education%20in%20Haiti%20`%20The%20Way%20Forward%20`%20FINAL%20`%209`15`08.pdf!

M.!Azaunce!(1995),!cited!in!Cultural!Consultation!Service,!Mental!health!in!Haiti:!A!literature!review!(February!2010).!Available!at!http://www.state.nj.us/humanservices/dmhs/disaster/MH_in_Haiti%20_Literature_Review.pdf!

M.!Baro,!"Food!insecurity!and!livelihood!systems!in!northwest!Haiti,"!Journal&of&Political&Ecology!9!(2002),!pp.!1`34.!!

M.!C.!Smith!Fawzi,!E.!Eustache,!C.!Oswald,!et!al.,!"Psychosocial!functioning!among!HIVàffected!youth!and!their!caregivers!in!Haiti:!Implications!for!family`focused!service!provision!in!high!HIV!burden!settings,"!AIDS&Patient&Care&and&STDs!24/3!(2010),!pp.!147`158.!!

M.!C.!Smith!Fawzi,!W.!Lambert,!J.!M.!Singler,!et!al.,!"Factors!associated!with!forced!sex!among!women!accessing!health!services!in!rural!Haiti:!Implications!for!the!prevention!of!HIV!infection!and!other!sexually!transmitted!diseases,"!Social&Science&&&Medicine!60/4!(2005),!pp.!679`689.!!

M.!C.!Smith!Fawzi,!W.!Lambert,!J.!M.!Singler,!et!al.,!"Prevalence!and!risk!factors!of!STDs!in!rural!Haiti:!implications!for!policy!and!programming!in!resource`poor!settings,"!International&Journal&of&STD&&&AIDS!14!(2003),!pp.!848`853.!!

M.!Cayemittes,!A.!Rival,!G.!Lerebours,!and!B.!Barrere,!Survey&on&mortality,&morbidity&and&utilization&of&

!References&


services&(EMMUS5II)&1994/95:&Summary&report,!Demographic!and!Health!Surveys!(November!1995).!Available!at!http://www.measuredhs.com/pubs/pdf/SR49/SR49.pdf!

M.!J.!N'Zengou`Tayo,!"Fanm!se!potomitan:!Haitian!woman!is!the!pillar!of!society,"!Feminist&Review!59!(1998),!pp.!118`142.!!

M.!J.!Small,!J.!Gupta,!R.!Frederic,!et!al.,!"Intimate!partner!and!nonpartner!violence!against!pregnant!women!in!rural!Haiti,"!International&Journal&of&Gynecology&and&Obstetrics!102!(2008),!pp.!226`231.!!

M.!Justesen!and!D.!Verner,!Factors&impacting&youth&development&in&Haiti,!World!Bank!policy!research!working!paper!No.!4110!(2007).!Available!at!http://ddpèxt.worldbank.org/EdStats/HTIprwp07.pdf!

M.!K.!Varma,!M.!L.!Satterthwaite,!A.!M.!Klasing,!et!al.,!"Woch!nan!soley:!The!denial!of!the!right!to!water!in!Haiti,"!Health&and&Human&Rights!10/2!(2008),!pp.!67`89.!!

M.!Loudon,!A&study&of&integrated&interventions&for&children&made&vulnerable&by&HIV/AIDS&in&Haiti:&A&case&

study&of&La&Maison&l'Arc5en5Ciel,!UNAIDS/UNICEF!(2006).!Available!at!http://www.unicef.org/lac/Haiti_Case_Study`Children_made_Vulnerable_by_AIDS(1).pdf!

Millennium!Project,!Countdown&to&2015:&2010&Country&profiles:&Haiti!(2010).!Available!at!http://www.countdown2015mnch.org/documents/2010report/Profile`Haiti.pdf!

MSPP,!Rapports&journaliers&du&MSPP&sur&l'évolution&du&choléra&en&Haiti&(MSPP&daily&reports&on&the&

evolution&of&cholera&in&Haiti)!(1!January!2012).!Available!at!http://mspp.gouv.ht/site/download.php?file=downloads/Rapport%20journalier%20MSPP%20du%2001%20janvier%202012.pdf!

N.!Caistor,!Haiti’s&history&of&misery,!BBC!News!(13!January!2010).!Available!at!http://news.bbc.co.uk/2/hi/americas/8456728.stm!

N.!Romera`Daza,!A.!Ruth,!and!M.!Denis`Luque,!"An!alternative!model!for!the!provision!of!Sservices!to!HIV`positive!orphans!in!Haiti,"!Journal&of&the&Health&Care&for&the&Poor&and&Underserved!20/4!(2009),!pp.!36`40.!!

O.!A.!Adetayo,!A.!Gabriel,!and!S.!C.!Gupta,!"Haiti!and!the!road!to!recovery:!Surviving!the!human!aftershocks,!battles!with!the!cholera!epidemic,!and!the!anticipation!of!a!new!political!era,"!Plastic&and&Reconstructive&Surgery!128/2!(2011),!pp.!577`578.!!

OMCT,!Rights&of&the&child&in&Haiti&(October!2002).!Available!at!http://www.omct.org/files/2001/11/1155/haitichildren2002.pdf!

Oxfam!America,!Aid&to&Haiti,&6&months&on:&a&long&way&to&go,!Oxfam!media!briefing!(July!2010).!Available!at!http://www.oxfamamerica.org/publications/aid`to`haiti`6`monthsònà`long`way`to`go/!

Oxfam!America,!Haiti:&A&once5in5a5century&chance&for&change,!Oxfam!Briefing!Paper!136!(March!2010).!Available!at!http://www.oxfamamerica.org/publications/haitiàònceìnà`century`chance`for`change!

Oxfam!International,!Haiti:&'A&gathering&storm':&Climate&change&and&poverty!(November!2009).!Available!

!


at!http://www.oxfam.org/en/policy/haiti`gathering`storm!

Oxfam,!Haitians&talk&about&rebuilding&the&country&after&the&January&12,&2010&earthquake!(March!2010).!Available!at!http://www.reliefweb.int/node/351160!

P.!Farmer,!C.!P.!Almazor,!E.!T.!Bahnsen,!et!al.,!"Meeting!cholera's!challenge!to!Haiti!and!the!world:!a!joint!statement!on!cholera!prevention!and!care,"!PLoS&Neglected&Tropical&Diseases!5/5!(2011),!pp.!e1145.!!

P.!Lawrence,!J.!Meigh,!and!C.!Sullivan,!The&water&poverty&index:&An&international&comparison,!Keele!Economics!Research!Paper!19!(October!2002).!Available!at!http://www`docs.tu`cottbus.de/hydrologie/public/scripte/lawrence_etal2002.pdf!

P.!S.!Pinheiro,!World!report!on!violence!against!children,!United!Nations!secretary`general's!study!on!violence!against!children,!UN!Doc.!A/61/299!(2006).!Available!at!http://www.unicef.org/violencestudy/reports/SG_violencestudy_en.pdf!!

PAHO,!EOC&situation&report&#1:&Cholera&outbreak&in&Haiti!(October!2010).!Available!at!http://new.paho.org/disasters/index.php?option=com_docman&task=doc_download&gid=1158!

PAHO,!Health&in&the&Americas&2007:&Volume&II&5&countries:&Haiti!(2007).!Available!at!http://www.paho.org/hia/archivosvol2/paisesing/Haiti%20English.pdf!

PAHO,!Health&situation&and&trends&summary:&Haiti!(2007).!Available!at!http://www.paho.org/English/DD/AIS/cp_332.htm!

PAHO,!Health&situation&in&Haiti&before&the&2010&earthquake,!Presentation!at!Haiti!Health!Cluster!(January!2010).!Available!at!http://ec.europa.eu/echo/files/aid/countries/Haiti_paper_01102010.pdf!

PAHO,!Regional&core&health&data&database:&Haiti.!Available!at!http://www.paho.org/english/sha/coredata/tabulator/newtabulator.htm!

PEPFAR,!2008&Country&profile:&Haiti!(2008).!Available!at!http://2006`2009.pepfar.gov/press/81593.htm!

Population!Council/UNFPA,!The&adolescent&experience&in5depth:&Using&data&to&identify&and&reach&the&most&vulnerable&young&people:&Haiti&2005/06!(2009).!Available!at!http://www.unfpa.org/youth/docs/AdolescentDataGuide_Haiti2005`06.pdf!

Population!Reference!Bureau,!PRB&datafinder:&Haiti.!Available!at!http://www.prb.org/datafinder.aspx!

R.!B.!Devin!and!P.!I!Erickson,!"The!influence!of!male!care!givers!on!child!health!in!rural!Haiti,"!Social&Science&&&Medicine!43/4!(1996),!pp.!479`488.!!

R.!C.!Archibold,!"New!Haitian!leader!pledges!reconciliation,"!New&York&Times!(April!5,!2011).!Available!at!http://www.nytimes.com/2011/04/06/world/americas/06haiti.html!

R.!de!Silva`de`Alwis,!Legislative&reform&on&child&domestic&labor:&A&gender&analysis,!UNICEF!Division!of!Policy!and!Planning!(January!2007).!Available!at!

!References&


http://www.unicef.org/policyanalysis/files/Leg_Reform_on_Child_Domestic_Labour(1).pdf!

S.!C.!Wortham,!"The!young!child!and!social!relationships!in!developing!countries,"!in!M.!R.!Jalongo!(ed),!Enduring&bonds:&the&significance&of&interpersonal&relationships&in&young&children's&lives!(Indiana:!Springer,!2007).!!

S.!Crabtree,!J.!Godoy,!and!J.!Ray,!Survey&highlights&Haitians'&vulnerability:&Access&to&food,&shelter,&healthcare&less&prevalent&than&in&neighboring&countries,!Gallup!(January!2010).!Available!at!http://www.gallup.com/poll/125075/survey`highlights`haitians`vulnerability.aspx!

S.!F.!Dowell,!J.!W.!Tappero,!and!T.!R.!Frieden,!"Public!health!in!Haiti!`!challenges!and!progress,"!New&England&Journal&of&Medicine!364/4!(2011),!pp.!300`301.!!

S.!Larose,!"The!Haitian!lakou:!Land,!family!and!ritual,"!in!A.!F.!Marks!and!R.!A.!Romer!(eds),!Family&and&

kinship&in&middle&America&and&the&Caribbean!(Leiden:!University!of!the!Netherlands!Antilles,!1976).!!

S.!Toupin,!Ensuring&haitian&women's&participation&and&leadership&in&all&stages&of&national&relief&and&

reconstruction:&A&gender&shadow&report&of&the&2010&Haiti&PDNA!(2010).!Available!at!http://reliefweb.int/node/350585!

Save!the!Children,!Serving&Haiti's&children&now,&rebuilding&for&their&future:&Six&months&after&the&massive&

quake!(July!2010).!Available!at!http://www.savethechildren.org/atf/cf/{9def2ebe`10ae`432c`9bd0`df91d2eba74a}/Haiti_6_month_report.pdf!

Sphere!Project,!“3.!Management!of!acute!malnutrition!and!micronutrient!deficiencies,”!in!Sphere!Project,!Humanitarian&charter&and&minimum&standards&in&humanitarian&response!(2011).!Available!at!http://www.spherehandbook.org/en/3`managementòfàcute`malnutritionànd`micronutrient`deficiencies/!

Sphere!Project,!Humanitarian&charter&and&minimum&standards&in&humanitarian&response!(2011).!Available!at!http://www.sphereproject.org/!

Sphere!Project,!Sphere&protection&section:&Draft!(June!23,!2011).!Available!at!http://www.crin.org/docs/FileManager/Sphere_Protection_Chapter_23Junedraft1.doc!

T.!Daniel,!"Haiti!mayor!says!he!plans!to!clear!huge!quake!camp,"!New&York&Times!(July!10,!2011).!Available!at!http://ijdh.org/archives/20587!

T.!Dorjgochoo,!F.!Noel,!M.!M.!Deschamps,!et!al.,!"Risk!factors!for!HIV!infection!among!Haitian!adolescents!and!young!adults!seeking!counseling!and!testing!in!Portàu`Prince,"!Journal&of&Acquired&Immune&Deficiency&Syndromes!52!(2009),!pp.!498`508.!!

T.!Sommerfelt!and!J.!Pederson,!"Child!Labor!in!Haiti,"!in!H.!D.!Hindman!(ed),!The&world&of&child&labor:&An&historical&and&regional&survey!(New!York:!M.E.!Sharpe,!Inc.,!2009).!!

T.!Sommerfelt,!Child&domestic&labour&in&Haiti:&Characteristics,&contexts&and&organisation&of&children's&

residence,&relocation&and&work,!FAFO!(May!2002).!Available!at!http://www.fafo.no/ais/other/haiti/childlabour/EEDH_Report_draft_english.pdf!

!


T.!S.!Betancourt,!R.!T.!Brennan,!J.!Rubin`Smith,!et!al.,!“Sierra!Leone’s!former!child!soldiers:!A!longitudinal!study!of!risk,!protective!factors,!and!mental!health,”!Journal&of&the&American&Academy&of&Child&and&

Adolescent&Psychiatry!49/6!(2010),!pp.!606`615.!Available!at!http://www.hsph.harvard.edu/mch`cyf`concentration/files/betancourt_et_al._2010_jaacap.pdf!

T.!T.!Schwartz,!Fewer&men,&more&babies:&Sex,&family&and&fertility&in&Haiti!(Lanham:!Lexington!Books,!2009).!!

Technical!Secretariat!of!the!Preparatory!Committee,!Growth&and&poverty&reduction&strategy&paper:&Republic&of&Haiti.!IMF!country!report!08/115!(November!2007).!Available!at!http://www.imf.org/external/pubs/ft/scr/2008/cr08115.pdf!

U.!Bronfenbrenner,!The&Ecology&of&Human&Development:&Experiments&by&Nature&and&Design!(Cambridge,!MA:!Harvard!University!Press,!1979).!

U.S.!Census!Bureau,!International&data&base:&Haiti&demographic&indicators.!Available!at!http://www.census.gov/population/international/data/idb/informationGateway.php!

U.S.!Department!of!Labor,!Findings&on&the&worst&forms&of&child&labor:&2006&report:&Haiti!(2006).!Available!at!http://www.dol.gov/ilab/map/countries/haiti.htm!

U.S.!Department!of!Labor,!Haiti,!Bureau!of!International!Labor!Affairs!(2011).!Available!at!http://www.dol.gov/ilab/media/reports/iclp/Advancing1/html/haiti.htm!

U.S.!Department!of!State,!Trafficking&in&persons&report&2009,!Office!to!Monitor!and!Combat!Trafficking!in!Persons!(June!2009).!Available!at!http://www.state.gov/documents/organization/123357.pdf!

U.S.!Department!of!State,!Trafficking&in&persons&report&2011,!Office!to!Monitor!and!Combat!Trafficking!in!Persons!(June!2011).!Available!at!http://www.state.gov/g/tip/rls/tiprpt/2011/index.htm!

U.S.!Geological!Survey,!Magnitude&7.0&5&Haiti&Region:&Details,!Earthquake!Hazards!Program!(2010).!Available!at!http://earthquake.usgs.gov/earthquakes/eqinthenews/2010/us2010rja6/#details!

U.S.!Geological!Survey,!Magnitude&7.0&5&Haiti&Region:&Summary,!Earthquake!Hazards!Program!(2010).!Available!at!http://earthquake.usgs.gov/earthquakes/eqinthenews/2010/us2010rja6/#summary!

UN!Committee!on!the!Rights!of!the!Child,!Concluding!observations:!Haiti,!UN!Doc.!CRC/C/15/Add.202!(2003).!Available!at!http://www.unhcr.org/refworld/docid/3f2597274.html!

UN!Committee!on!the!Rights!of!the!Child,!Consideration!of!reports!submitted!by!state!parties!under!article!44!of!the!Convention:!Haiti,!UN!Doc.!CRC/C/51/Add.7!(2002).!Available!at!http://www.unhcr.org/refworld/docid/3df59ad34.html!!

UN!DESA,!The&millennium&development&goals&report&2009!(New!York,!July!2009).!Available!at!http://www.un.org/en/development/desa/news/statistics/mdg`2009.shtml!

UN!DESA,!World&youth&report:&2007!(New!York:!United!Nations,!2007).!Available!at!http://www.un.org/esa/socdev/unyin/wyr07.htm!

!References&


UN!ESC,!Situation!of!human!rights!in!Haiti,!UN!Doc.!E/CN.4/2001/106!(2001).!Available!at!http://ap.ohchr.org/documents/dpage_e.aspx?m=47!!

UN!ESC,!Situation!of!human!rights!in!Haiti,!UN!Doc.!E/CN.4/2005/123!(2005).!Available!at!http://ap.ohchr.org/documents/dpage_e.aspx?m=47!

UN!ESC,!Situation!of!human!rights!in!Haiti,!UN!Doc.!E/CN.4/2006/115!(2006).!Available!at!http://ap.ohchr.org/documents/dpage_e.aspx?m=47!

UN!GA,!Report!of!the!special!rapporteur!on!contemporary!forms!of!slavery,!including!its!causes!and!consequences,!Gulnara!Shahinian,!UN!Doc.!A/HRC/12/21/Add.1!(2009).!Available!at!http://www.unhcr.org/refworld/docid/4ac0c6b42.html!

UN!GA,!Situation!of!human!rights!in!Haiti,!UN!Doc.!A/54/366!(1999).!Available!at!http://www.unhcr.org/refworld/docid/3b00f2431c.html!

UN!GA,!Situation!of!human!rights!in!Haiti,!UN!Doc.!A/55/335!(2000).!Available!at!http://www.un.org/documents/ga/docs/55/a55335.pdf!!

UN!GA,!Situation!of!human!rights!in!Haiti,!UN!Doc.!A/HRC/4/3!(2007).!Available!at!http://www.unhcr.org/refworld/docid/461f2e552.html!

UN!MINUSTAH,!Haiti:&6&Months&after…!(July!2010).!Available!at!http://www.un.org/en/peacekeeping/missions/minustah/documents/6_months_after_commemoration.pdf!

UN!MINUSTAH,!IDP&camp&joint&security&assessment&report,!MINUSTAH!Human!Rights!Section!(March!2010).!Available!at!http://oneresponse.info/Disasters/Haiti/Protection/publicdocuments/Joint%20Security%20Assessment%20report%20`%20Final.doc!

UN!MINUSTAH,!Press&Conference&by&Deputy&Special&Representative&of&Secretary5General&for&Haiti!(30!November!2011).!Available!at!http://minustah.org/?p=32936!

UN!News!Center,!Cholera&inter5sector&response&strategy&for&Haiti:&November&2010&5&December&2011&

(2011).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/8B2E07AB1A31BABEC12577D8004FE057`Full_Report.pdf!

UN!OCHA!Haiti,!Haiti&before&January&12th,&Internal&document!(2010).!Available!at!http://ochaonline.un.org/OchaLinkClick.aspx?link=ocha&docId=1165439!

UN!OCHA!Haiti,!Haiti:!Humanitarian!assessment!key!findings!No.!1,&22&March&2010!(March!2010).!Available!at!http://haiti.cridlac.org/XML/eng/doc90885/doc90885`contenido.pdf!

UN!OCHA!Haiti,!Haiti:&Humanitarian&assessment&key&findings&No.&2,&29&March&2010!(March!2010).!Available!at!http://groups.google.com/group/assessmentshaiti/browse_thread/thread/71f3f127213f7a06!

!


UN!OCHA!Haiti,&Haiti:&Humanitarian&assessment&key&findings&No.&3,&5&April&2010!(April!2010).!Available!at!http://groups.google.com/group/assessmentshaiti/browse_thread/thread/71f3f127213f7a06!

UN!OCHA!Haiti,!Haiti:&Humanitarian&assessment&key&findings&No.&4!(April!2010).!!

UN!OCHA!Haiti,!Haiti:&Humanitarian&indicator&and&presence&report&(September!2010).!Available!at!http://oneresponse.info/Disasters/Haiti/Education/publicdocuments/education_dashboard_ENG.pdf!

UN!OCHA,!Humanitarian&bulletin:&1&July&5&25&July&2011&(July!2011).!Available!at!http://haiti.humanitarianresponse.info/LinkClick.aspx?link=Nutrition+Cluster%2f1_Juillet_25Juillet2011_Haiti_Humanitarian_Bulletin.pdf&tabid=80&mid=1033!

UN!OCHA,!Humanitarian&bulletin:&19&August&5&20&September&2011!(September!2011).!Available!at!http://haiti.humanitarianresponse.info/LinkClick.aspx?link=Nutrition+Cluster%2f19_Aout_20_Septembre_2011_Haiti+_Humanitarian_Bulletin+10+English.pdf&tabid=80&mid=1033!

UN!OCHA,!Humanitarian&bulletin:&3&May&5&6&June&2011!(2011).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/Full_Report_1060.pdf!

UN!ODC,!Signatories&to&the&CTOC&trafficking&protocol!(2011).!Available!at!http://www.unodc.org/unodc/en/treaties/CTOC/countrylist`traffickingprotocol.html!

UN!Treaty!Collection,!Status:&Convention&on&the&rights&of&the&child&(2011).!Available!at!http://treaties.un.org/Pages/ViewDetails.aspx?src=IND&mtdsg_no=IV`11&chapter=4&lang=en!

UNAIDS,!Children&and&AIDS:&A&stocktaking&report&(January!2007).!Available!at!http://www.unicef.org/publications/index_38048.html!

UNAIDS,!Children&and&AIDS:&Fourth&stocktaking&report,&2009!(December!2009).!Available!at!http://www.unicef.org/publications/index_51902.html!

UNAIDS,!Helping&Haiti&rebuild&its&AIDS&response!(February!2010).!Available!at!http://data.unaids.org/pub/FactSheet/2010/20100226_haiti_aidsresponse_en.pdf!

UNDP!Haiti!Country!Office,!Rapport&national&sur&le&développement&humain&2002&(Haiti&national&human&

development&report):&La&bonne&gouvernance:&Un&defi&majeur&pour&le&developpement&humain&durable&en&

Haiti!(2002).!Available!at!http://www.ht.undp.org/public/publicationdetails.php?idpublication=11!

UNDP,!Human&development&report&1999:&Globalization&with&a&human&face&(New!York:!Palgrave!Macmillan,!1999).!Available!at!http://hdr.undp.org/en/reports/!

UNDP,!Human&development&report&2000:&Human&rights&and&human&development!(New!York:!Palgrave!Macmillan,!2000).!Available!at!http://hdr.undp.org/en/reports/!

UNDP,!Human&development&report&2007/08:&Fighting&climate&change!(New!York:!Palgrave!Macmillan,!2008).!Available!at!http://hdr.undp.org/en/reports/!

UNDP,!Human&development&report&2009:&Overcoming&barriers:&Human&mobility&and&development!(New!

!References&


York:!Palgrave!Macmillan,!2009).!Available!at!http://hdr.undp.org/en/reports/!

UNDP,!Human&development&report&2010:&The&real&wealth&of&nations:&Pathways&to&human&development!(New!York:!Palgrave!Macmillan,!2010).!Available!at!http://hdr.undp.org/en/reports/!

UNESCO,!Data&center:&Custom&tables:&Haiti.!Available!at!http://stats.uis.unesco.org/unesco/TableViewer/document.aspx?ReportId=136&IF_Language=eng&BR_Topic=0!

UNESCO,!Education&for&all&database:&Haiti.!Available!at!http://www.uis.unesco.org/ev.php?URL_ID=5262&URL_DO=DO_TOPIC&URL_SECTION=201!

UNESCO,!Education&indicators:&Technical&guidelines,&UNESCO&Institute&for&Statistics!(November!2009).!Available!at!http://www.uis.unesco.org/Library/Pages/default.aspx!

UNESCO,!Haiti:&Early&childhood&care&and&education&(ECCE)&programmes,!UN!Doc.!IBE/2006/EFA/GMR/CP/36!(2006).!Available!at!http://unesdoc.unesco.org/images/0014/001480/148026e.pdf!

UNESCO,!Net&enrollment&ratios&(2011).!Available!at!http://glossary.uis.unesco.org/glossary/en/home!

UNESCO,!Net&intake&rate!(2011).!Available!at!http://glossary.uis.unesco.org/glossary/en/home!

UNHCR,!Driven&by&desperation:&Transactional&sex&as&a&survival&strategy&in&Port5au5Prince&IDP&camps!(May!2011).!Available!at!http://haiti.humanitarianresponse.info/LinkClick.aspx?fileticket=w`7_7C8C`2o%3d&tabid=81&mid=1413!

UNICEF!Executive!Board,!Revised&country&programme&document:&Haiti&(200952011)!(2009).!Available!at!http://www.unicef.org/about/execboard/files/Haiti`FRS2009`revised_feb2010`English.pdf!

UNICEF,!At&a&glance:&Haiti!(March!2010).!Available!at!http://www.unicef.org/infobycountry/haiti_statistics.html!

UNICEF,!Child&protection&information&sheets!(May!2006).!Available!at!http://www.unicef.org/publications/files/Child_Protection_Information_Sheets.pdf!

UNICEF,!Child&Protection&Information&Sheet:&Children&without&parental&care!(May!2006).!Available!at!http://www.unicef.org/chinese/protection/files/Parental_Care.pdf!

UNICEF,!Child!protection:!A!handbook!for!parliamentarians,&Handbook&for&Parliamentarians&No.&7!(2004).!Available!at!http://www.unicef.org/publications/files/Guide_Enfants_OK.pdf!

UNICEF,!Children&in&Haiti:&One&year&after&5&the&long&road&from&relief&to&recovery&(January!2011).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/10CF91515919332F49257811001C26F3`Full_Report.pdf!

UNICEF,!Children&of&Haiti:&Milestones&and&looking&forward&at&six&months!(July!2010).!Available!at!http://www.unicef.org/emerg/files/UNICEF_Haiti_`_Six_Months_Report_Final.pdf!

!


UNICEF,!Children&of&Haiti:&Progress,&gaps&and&plans&in&humanitarian&action!(April!2010).!Available!at!http://www.unicef.org/romania/FINAL_UNICEF_Haiti_90`Day_Report_13_April_2010_FINAL.pdf!

UNICEF,!Field&diary:&Fighting&child&trafficking&on&Haiti's&border!(February!2011).!Available!at!http://www.unicef.org/infobycountry/haiti_57675.html!

UNICEF,!OHCHR&Universal&Periodic&Review&–&Haiti!(March!2011).!Available!at!http://lib.ohchr.org/HRBodies/UPR/Documents/session12/HT/UNICEF`eng.pdf!

UNICEF,!Orphans!(February!2009).!Available!at!http://www.unicef.org/media/media_45279.html!

UNICEF,!Progress&for&children&number&4:&A&report&card&on&nutrition!(May!2006).!Available!at!http://www.unicef.org/progressforchildren/2006n4/files/PFC4_EN_8X11.pdf!

UNICEF,!Progress&for&children&number&7:&A&report&card&on&maternal&mortality!(September!2008).!Available!at!http://www.unicef.org/progressforchildren/files/Progress_for_Children`No._7_Lo`Res_082008.pdf!

UNICEF,!Progress&for&children&number&8:&A&report&card&on&child&protection!(September!2009).!Available!at!http://www.unicef.org/protection/files/Progress_for_Children`No.8_EN_081309(1).pdf!

UNICEF,!Residential&care&center&provides&a&refuge&for&street&children&in&Cap5Haitian!(February!2011).!Available!at!http://www.unicef.org/infobycountry/haiti_57670.html!

UNICEF,!State&of&the&world's&children&1997!(Oxford:!Oxford!University!Press,!1997).!Available!at!http://www.unicef.org/sowc/!








UNICEF,!State&of&the&world's&children&2011!(Oxford:!Oxford!University!Press,!2011).!Available!at!

!References&


http://www.unicef.org/sowc/!

UNICEF,!State&of&the&world's&children&database.!Available!at!http://www.unicef.org/statistics/index_step1.php!

UNICEF,!The&'rights'&start&to&life:&A&statistical&analysis&of&birth&registration!(February!2005).!Available!at!http://www.unicef.org/publications/index_25248.html!

UNICEF,!The&state&of&Latin&American&and&Caribbean&children&2008:&Child&survival!(May!2008).!Available!at!http://www.unicef.org/publications/files/SOLAC_2008_EN_041408.pdf!

UNICEF,!UNICEF&humanitarian&action&report&2007&(2007).!Available!at!http://www.unicef.org/har07/index_37587.htm!

UNICEF,!UNICEF&humanitarian&action&report&2008!(2008).!Available!at!http://www.unicef.org/har08/index_haiti.php!

UNICEF,!UNICEF&rebuilds&education&in&Haiti&from&the&ruins&(January!2011).!Available!at!http://www.unicef.org/malaysia/media_news11ùnicef`rebuildsèducationìn`haiti`from`the`ruins.html!

Unofficial!translation!provided!by!Global!Initiative!to!End!All!Corporal!Punishment!of!Children,!Haiti&country&report!(February!2009).!Available!at!http://www.endcorporalpunishment.org/!

V.!Jules!and!A.!Panneflek,!Subregional&synthesis&report:&Volume&I&5&Summary,!Education!for!all!in!the!Caribbean:!Assessment!2000!(2000).!Available!at!http://www.unesco.org/carneid/synthesis`1.pdf!

WHO!CRED,!Haiti:&A&brief&analysis&of&surveys&from&2004&to&2005,!Briefing!note!243,!Complex!Emergency!Database!(March!2008).!Available!at!http://www.cedat.be/sites/default/files/Brief%20243%20`%20Haiti.pdf!

WHO,!Epidemiological&fact&sheet&on&HIV&and&AIDS:&Haiti!(December!2008).!Available!at!http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_HT.pdf!

WHO,!Global&health&observatory&database:&Haiti.!Available!at!http://www.who.int/gho/en/!

WHO,!Life&tables&for&WHO&member&states:&Haiti.!Available!at!http://www.who.int/healthinfo/statistics/mortality_life_tables/en/!

WHO,!Mortality&country&fact&sheet&2006:&Haiti!(2007).!

WHO/UNICEF,!WHO&and&UNICEF&estimates&of&immunization&coverage:&2010&revision:&Haiti!(2010).!Available!at!http://www.who.int/immunization_monitoring/data/hti.pdf!

World!Bank,!A&review&of&gender&issues&in&the&Dominican&Republic,&Haiti&and&Jamaica,!Report!No.!21866`LAC!(2002).!Available!at!http://www`wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2003/03/22/000094946_03030704005682/Rendered/PDF/multi0page.pdf!

World!Bank,!Genderstats&database:&Latin&America&and&the&Caribbean.!Available!at!

!


http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTGENDER/EXTANATOOLS/EXTSTATINDDATA/EXTGENDERSTATS/0,,contentMDK:21442622~menuPK:4851685~pagePK:64168445~piPK:64168309~theSitePK:3237336,00.html!

World!Bank,!Social&resilience&and&state&fragility&in&Haiti:&A&country&social&analysis,!Caribbean!Country!Management!Unit,!Report!no.!36069`HT!(April!2006).!Available!at!http://siteresources.worldbank.org/SOCIALANALYSIS/1104894`1115795935771/20938696/Haiti_CSA.pdf!

World!Bank,!World&databank&education&statistics&(EdStats).!Available!at!http://data.worldbank.org/data`catalog/ed`stats!

World!Bank,!World&development&indicator&database.!Available!at!http://databank.worldbank.org/ddp/home.do?Step=12&id=4&CNO=2!

World!Food!Program,!Food&security&analysis!(2010).!Available!at!http://www.wfp.org/food`security!

World!Vision,!A&call&to&Action:&Haiti&at&6&months!(June!2010).!Available!at!http://www.worldvision.com.au/Libraries/HEA_reports/A_Call_to_Action_`_Haiti_at_6_months.sflb.ashx!

World!Vision,!Rapid&assessment&report:&Haiti&earthquake&response!(March!2010).!Available!at!http://reliefweb.int/sites/reliefweb.int/files/resources/Full_Report_583.pdf!

Y.!M.!Edmond,!S.!M.!Randolph,!and!G.!L.!Richard,!"The!lakou!system:!A!cultural,!ecological!analysis!of!mothering!in!rural!Haiti,"!Journal&of&Pan&African&Studies!2/1!(2007),!pp.!19`32.!!

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