Climate and Health Vulnerability Assessment HAITI © 2024 International Bank for Reconstruction and Development/The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory, or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. The World Bank encourages the dissemination of its knowledge; thus this work may be reproduced, in whole or in part, for noncommercial purposes, as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Cover image: Dajaban Haiti - July 15, 2011: Haitian woman carries a bucket of goods on her head while men carry a poultry crate and sack of grains at Haitian Dominican Republic border market. HAITI Climate and Health Vulnerability Assessment March 2024 CLIMATE INVESTMENT FUNDS CONTENTS ACKNOWLEDGMENTS..................................................................................................................vii LIST OF ABBREVIATIONS............................................................................................................viii EXECUTIVE SUMMARY................................................................................................................... 1 INTRODUCTION.............................................................................................................................. 3 Country Context..................................................................................................................................................... 3 Aims of assessment and conceptual framework............................................................................................. 3 CLIMATOLOGY..................................................................................................................................7 Haiti’s Geography................................................................................................................................................... 7 Observed and Projected Climate and Sea-Level Rises (SLRs) .................................................................... 8 Climate-related Hazards..................................................................................................................................... 10 Floods.........................................................................................................................................................................10 Hurricanes.................................................................................................................................................................12 Landslides.................................................................................................................................................................13 Droughts....................................................................................................................................................................14 Rising Temperatures ..............................................................................................................................................15 Wildfires.....................................................................................................................................................................16 CLIMATE-RELATED HEALTH RISKS.............................................................................................19 Nutrition risks .......................................................................................................................................................22 Waterborne and water-related diseases ........................................................................................................25 Vector-Borne Diseases (VBDs) .........................................................................................................................27 Malaria.......................................................................................................................................................................27 Dengue.....................................................................................................................................................................30 Heat-Related Morbidity and Mortality .............................................................................................................32 Air Quality Health Risks......................................................................................................................................33 Mental Health and Well-being...........................................................................................................................34 ADAPTIVE CAPACITY................................................................................................................... 39 Health system overview.....................................................................................................................................39 Leadership and Governance.............................................................................................................................40 Health workforce..................................................................................................................................................42 Health information and disease surveillance systems.................................................................................44 Essential medical products and technologies...............................................................................................45 Health Service Delivery .....................................................................................................................................46 Financing................................................................................................................................................................48 iv | Climate and Health Vulnerability Assessment: Haiti RECOMMENDATIONS TO ENHANCE HEALTH SYSTEM RESILIENCE TO CLIMATE CHANGE..........................................................................................................................................51 Leadership and Governance.............................................................................................................................52 Health financing...................................................................................................................................................52 Service Delivery...................................................................................................................................................52 Health workforce..................................................................................................................................................53 Health Information Systems...............................................................................................................................53 ANNEXES ....................................................................................................................................... 55 Annex A. Methods for estimating mosquito suitability in Haiti, under RCP8.5 ......................................55 Annex B. Assumptions on the course of future global climate change ..................................................55 REFERENCES................................................................................................................................. 57 LIST OF FIGURES Figure 1. World Health Organization (WHO) operational framework for climate-resilient healthcare systems......................................................................................................................................................... 5 Figure 2. Administrative boundaries of Haiti’s departments................................................................................ 5 Figure 3. Projected average monthly temperatures and precipitation levels in Haiti................................... 8 Figure 4. Total population living below 1 m above the sea level in Haiti, by department............................10 Figure 5. Hurricane Matthew’s trajectory in the Caribbean Basin.....................................................................12 Figure 6. Risk of landslide hazard..............................................................................................................................14 Figure 7. Hazard climate drought zones...................................................................................................................15 Figure 8. Top 10 causes of total number of deaths in 2019 and percentage change, 2009–2019, all ages combined........................................................................................................................................................ 20 Figure 9. Top 10 risks contributing to the total number of DALYs in 2019 and percent change, 2009–2019 — all ages combined..............................................................................................................................21 Figure 10. Stages of the food system that drive healthy and sustainable diets............................................23 Figure 11. Acute food insecurity, Sept 2021 (Rural + Urban)..............................................................................24 Figure 12. Enteric infections deaths per 100,000 in the LAC region................................................................26 Figure 13. Geographic and temporal distribution of malaria vectors...............................................................29 Figure 14. Spatial and temporal distribution of dengue vectors........................................................................31 Figure 15. WHO’s health system building blocks..................................................................................................40 Figure 16. WHO’s Operational framework for building climate-resilient health systems............................51 Contents | v LIST OF TABLES Table 1. Projections on precipitation extremes for the 2030s and the 2050s, based on a high-emissions scenario of RCP8.5...........................................................................................................................11 Table 2. Heat index days (> 35°C) anomaly projections, under high-emissions scenario RCP8.5...........16 Table 3. Flood and storm events in Haiti from 1991 to 2020..............................................................................21 Table 4. Child stunting, wasting, and mortality rates, by department.............................................................24 Table 5. Number of malaria cases in Haiti in 2014, by geographic department..........................................28 Table 6. Current and projected suitable areas for malaria vectors, by department...................................29 Table 7. Vulnerable populations and areas suitable for malaria vectors........................................................30 Table 8. Regional and global comparisons of deaths attributable to outdoor air pollution, household air pollution, and fine particulate matter in Haiti, 2016.................................................................. 34 Table 9. Summary of the Climate Change Risks on Health Outcomes..........................................................36 Table 10. Key policies and action plans in Haiti that consider climate change challenges.......................40 Table 11. Number of healthcare facilities, by type, across provinces............................................................. 47 Table 12. Summary of the health system adaptive capacity gaps for Haiti...................................................50 vi | Climate and Health Vulnerability Assessment: Haiti ACKNOWLEDGMENTS This Climate and Health Vulnerability Assessment (CHVA) for Haiti was produced by the Health- Climate, Environment and Disasters (HCED) program in the Health, Nutrition and Population (HNP) Global Practice of the World Bank, which is led by Tamer Rabie. It is authored by April Frake, Christopher Boyer, Mikhael Iglesias, Claire Bayntun, Stephen Dorey, and Tamer Rabie. The authors sincerely appreciate the valuable contributions provided by Ana Lucrecia Rivera-Rivera, Muloongo Simuzingili, and Loreta Rufo. This work also benefited from the administrative support of Fatima-Ezzahra Mansouri, the editorial work of Kah Ying Choo, and the production of Sarah Jene Hollis. The authors are also highly grateful to the HNP management for their strong support of the HCED program and this product and would like to extend their thanks to Juan Pablo Uribe and Monique Vledder. The authors are thankful to the Africa Climate Resilient Investment Facility (AFRI-RES) Trust Fund, Climate Investment Funds (CIF) and the Climate Support Facility (CSF) for funding this work. Acknowledgments | vii LIST OF ABBREVIATIONS AAP Ambient Air Pollution AIDS Acquired Immunodeficiency Syndrome AR6 Assessment Report 6 [of the IPCC] CCKP Climate Change Knowledge Portal [of World Bank] CFP Ciguatera Fish Poisoning CHVA Climate and Health Vulnerability Assessment CHE Current Health Expenditure CHEVT Climate and Health Economic Valuation Tool CMIP5 Coupled Model Intercomparison Project Phase 5 COPD Chronic Obstructive Pulmonary Disease COVID-19 Coronavirus 2019 CRU Climatic Research Unit [University of East Anglia, UK] CVD Cardiovascular Disease DALYs Disability Adjusted Life Years DCC Direction des Changements Climatique DRM Disaster Risk Management EU European Union FCV Fragility, Conflict, and Violence GBS Guillain-Barré Syndrome GCCA Global Climate Change Alliance GCM General Circulation Model GDP Gross Domestic Product GHG Greenhouse Gas [emissions] GWP Global Warming Potential HAP Household Air Pollution HFG Health Finance and Governance HIS Health Information System(s) HIV Human Immunodeficiency Virus HNAP Haiti National Adaptation Plan HNP Health, Nutrition and Population HRH Human Resources for Health HSS Health Systems Strengthening ICU Intensive Care Unit IHME Institute for Health Metrics and Evaluation IHR International Health Regulation INDC Intended Nationally Determined Contribution(s) IPC Integrated Food Security Phase Classification IPCC Intergovernmental Panel on Climate Change LAC Latin America and the Caribbean LULC Land Use and Land Cover MDE Ministère de L’Environnement MSPP Ministère de la Santé Publique et la Population NAP National Adaptation Plan NAPA National Adaptation Plan of Action NCD Noncommunicable Disease viii | Climate and Health Vulnerability Assessment: Haiti NDC Nationally Determined Contribution(s) NOAA National Oceanic and Atmospheric Administration NGO Nongovernmental Organization OFATMA Office d’Assurance Accident du Travail, Maladie et Maternité ONA Office National d’Assurance Vieillesse OOP Out-of-Pocket (spending on health) PAHO Pan American Health Organization PES Essential Service Package PHC Primary Health Care PIH Partners in Health PM2.5 Fine Particulate Matter PSDH Strategic Development Plan of Haiti PSP Paralytic Shellfish Poisoning PTG Post-Traumatic Growth RCP Representative Concentration Pathway SIDS Small Island Developing State SLCP Short-Lived Climate Pollutant SLR Sea-Level Rise SOPs Standard Operating Procedures SPEI Standardized Precipitation Evapotranspiration Index SPCR Strategic Program for Climate Resilience SDGs Sustainable Development Goals STMM Short-Term Medical Mission UHC Universal Health Coverage USAID United States Agency for International Development VBD Vector-Borne Disease WaSH Water, Sanitation, and Hygiene WBD Waterborne Disease WHO World Health Organization   List of Abbreviations | ix EXECUTIVE SUMMARY Haiti is highly vulnerable to the impacts of climate change due to its geographic location, low economic development, and limited resources. The country’s geograph- ical location — characterized by its presence on the Atlantic hurricane belt and on a low-lying coastal plain — makes it particularly susceptible to sea- level rises (SLRs), rising temperatures, hurricanes, and heavy rainfalls — all of which are projected to become more frequent and intense due to global warming. Over the past 30 years, Haiti has experienced 34 flooding events, 35 significant storms, and 31 hurricanes including Hurricane Matthew in 2016. Haiti also experiences periodic droughts that have impacted its agricultural production and exacerbated food insecurity. Climatic hazards are also exacerbating Haiti’s vulnerability to fragility, conflicts, and violence (FCV), further stressing the need for immediate action. Climate-related hazards — such as hurricanes, droughts, and floods — have destroyed crops, disrupted food production, and led to food insecurity and malnutrition. This can contribute to further social unrest and conflicts, especially among vulnerable communities. Severe weather events impacting the country have also caused significant damage to infrastructure, homes, and communities, forcing people to flee their homes and seek refuge elsewhere. Climate hazards in Haiti have also disrupted economic activity and caused significant losses to agriculture, fisheries, and other livelihoods, thereby exacerbating poverty and unemployment, and likely contributing to social instability and conflict. These factors highlight the importance of addressing the underlying vulnerabilities that make Haiti susceptible to FCV and of taking effective measures to mitigate and adapt to the impacts of climate change. Climate-related health risks in Haiti are significant; they are projected to increase the disease burden of the country. Identified climate-related health risks include (1) increased injuries and fatalities due to extreme weather events, (2) increased heat-related morbidity and mortality, (3) increased nutritional risks, (4) increases in water-related diseases, (5) increases in vector-borne diseases (VBDs), (6) exacerbation of respiratory risks, and (7) decline of physical / mental health and well-being. While the government of Haiti is committed to addressing climate change through multiple national plans, further efforts are required to strengthen the adaptive capacity of the country’s health system to address its growing needs. Notably, the country still lacks adequate funding for climate-health programming and infrastructure, as well as adequate integration of climate-informed interventions such as early-warning monitoring systems. 1 Five key recommendations are proposed in this CHVA to improve the health system’s adaptive capacity to growing climate-related health risks: 1. Incorporate climate change into health plans and strategies, thus creating a governance and policy landscape that would contribute to strengthening the country’s health system resiliency. 2. Provide budget lines to channel funding for implementing climate-health interventions. 3. Strengthen health service delivery amid extreme weather events and prioritize support for frontline communities. 4. Expand information systems that are already in place, such as Haiti Data, thus enabling the collection and analysis of climate and health data. 5. Develop building codes that are aimed at strengthening the existing health facilities’ resiliency to climate hazards. 2 | Climate and Health Vulnerability Assessment: Haiti SECTION I. INTRODUCTION COUNTRY CONTEXT 1. Haiti is highly vulnerable to the impacts of climate change — due to its geographic location, low economic development, and limited resources. Haiti’s geographical location — characterized by its presence on the Atlantic hurricane belt and a low-lying coastal plain — makes the country particularly susceptible to sea-level rises (SLRs), rising temperatures, hurricanes, and heavy rainfalls, which are projected to become more frequent and intense due to global warming. Over the past 30 years, Haiti has experienced 34 flooding events, 35 significant storms, and 31 hurricanes including Hurricane Matthew in 2016. Haiti is also affected by periodic droughts that have impacted its agricultural production and exacerbated food insecurity. 2. Climatic hazards are also exacerbating AIMS OF ASSESSMENT AND Haiti’s vulnerability to fragility, conflict, and violence (FCV), further magnifying the CONCEPTUAL FRAMEWORK need for immediate action. Climate-related 3. The objective of this Climate and Health hazards, such as hurricanes, droughts, and Vulnerability Assessment (CHVA) is to assist floods, have destroyed crops, disrupted food decision-makers with planning effective production, and led to food insecurity and adaptation measures to deal with climate- malnutrition. This can contribute to further related health risks. Where available, these social unrest and conflicts, especially among measures are also provided at the subnational vulnerable communities. Severe weather level to assist regional health planners. The events impacting the country have also recommendations of this CHVA are primarily caused significant damage to infrastructure, aimed at the health sector; however, related homes, and communities, forcing people to sectors influencing health risks that stem flee their homes and seek refuge elsewhere. from climate changes, such as DRM, are also Climate hazards in Haiti have also disrupted included. The target audience includes, but is economic activity and caused significant not limited to, the country’s Ministry of Health, losses to agriculture, fisheries, and other Ministry of Environment, and any other ministry livelihoods, thereby exacerbating poverty involved in addressing climate-related health and unemployment, and likely contributing risks, as well as nongovernmental organiza- to social instability and conflicts. These factors tions (NGOs) that are involved in supporting highlight the importance of addressing the projects and programs for the health system underlying vulnerabilities that make Haiti in Haiti. susceptible to FCV and of taking effective measures to mitigate and adapt to the impacts 4. Adaptation priorities need to run alongside of climate change. fundamental and urgent action to mitigate 3 climate change. It is important to stress 6. The World Health Organization’s (WHO) how complex the climate challenge is and operational framework for building climate-re- how hard it is to predict with accuracy how silient health systems is adopted to analyze severe climate exposures facing populations the adaptive capacity to adequately deal with will become. There are many factors that current and future identified risks. Based could slightly slow or significantly speed on this framework (Figure 1), the assessment up the rates of change, including positive is structured around the six health systems feedback effects and, most worrying of all, strengthening (HSS) building blocks. These cascading climatological tipping points. For six categories offer a structure for organizing this reason, mitigating existing greenhouse the assessment of capacities and gaps — now gas emissions (GHGs), as well as developing and into the future. The framework then moves and implementing measures to protect human on to consider WHO’s operational framework development from the changing climate, is to develop the Recommendations section. of paramount importance. 7. This assessment follows a stepwise linear 5. Investing in adaptation strategies to approach. The first step characterizes the proactively address the effects of climate climatology in Haiti — highlighting the change on health outcomes is critical. This observed and future climate exposures assessment is focused on the climate risks relevant to health. The second step examines to health and health systems, the adaptive climate-related health risks, including capacities in place to deal with these risks, identifying vulnerable populations. The final and the recommendations to meet identified step assesses the adaptive capacity of the gaps. The primary focus of this assessment is, health system — identifying gaps for the therefore, on climate adaptation and resilience management of current and future climate-re- measures. However, as the Assessment lated health risks. Together, these steps inform Report Six (AR6)1 of the Intergovernmental a series of recommendations for reducing Panel on Climate Change (IPCC) makes clear, climate-related health vulnerability in Haiti. “Global surface temperature will continue to The assessment is based on a review of the increase until at least the mid-century under published literature, as well as national and all emissions scenarios considered.” Mitigation international quantitative and qualitative data. is no longer a sufficient strategy, regardless of the pace of the response of governments and 8. The assessment incorporates subnational communities around the world. Adaptation considerations for health-related climate is now as critical a part of climate action as action. Within the context of this assessment, mitigation.  Therefore, although this report 10 administrative departments of Haiti were is focused on adaptation measures, it also considered: Artibonite, Centre, Grand’Anse, includes recommendations on reducing the Nippes, Nord, Nord-Est, Nord-Ouest, Ouest, healthcare sector’s carbon footprint. Sud-Est, and Sud (Figure 2). 4 | Climate and Health Vulnerability Assessment: Haiti FIGURE 1. World Health Organization (WHO) operational framework for climate-resilient healthcare systems ATE RESILIENCE CLIM hip & Heal eaders nce Workf th L verna orce Go V uln pac ation t Fin alth & A Ca apt men He ate era ity & Leadership As g d ss Clim cin bil & Governance Health se ity, an Workforce Financing Preparedness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential C li o r m e h Re ima & I n f a lt s Medical ma d C l a lt h se te Products & h He ra m Pro te a rc Technologies He - g Ma t na ien Env ge m ent o t e Re s il f C li m a le ir o n in a b D et m ental & S u st a gies ri m e l o of H n ts Techno cture e a lt h s tr u & Infra Source: World Health Organization, 2015, Operational Framework for Building Climate Resilient Health Systems. FIGURE 2. Administrative boundaries of Haiti’s departments Source: World Bank Cartography Unit. Introduction | 5 SECTION II. CLIMATOLOGY 9. This section describes observed climatic changes and projected climate trends, highlighting priority climate-related exposures that should be considered in relation to human health risks. Climate information is taken from the World Bank Group’s Climate Change Knowledge Portal (CCKP), where historical, observed data is derived from the Climatic Research Unit, University of East Anglia (CRU). Observed changes in mean annual temperatures, mean maximum temperatures, mean minimum temperatures, and precipitation levels from the CCKP are derived from the CRU TS version 4.05 gridded dataset for the 1901–2020 period. Model-based climate projection data is derived from the Coupled Model Intercomparison Project Phase 5 (CMIP5) collection. CMIP5 is a standard framework for the analysis of coupled atmosphere-ocean general circulation models (GCMs), providing estimates of future temperature and precipitation scenarios. Projected changes are explored under the IPCC representative concentration pathway (RCP) 8.5a for the short term (2030s; 2020–2039) and the medium term (2050s; 2040–2059). HAITI’S GEOGRAPHY to northwest, with a width of 30 km. To the southwest of the Central Plateau are the 10. Haiti is  predominantly  situated on the Montagnes Noires, with elevations of up to western portion of the island of Hispaniola approximately 600 m. in the Caribbean Sea, with smaller islands surrounding the country, including Île-à- The southern region consists of the Plaine Vache, Gonâve, Grosse Caye, Les Cayemites, du Cul-de-Sac and the mountainous southern Navassa, and Tortuga Island. The mainland peninsula. The Plaine du Cul-de-Sac is a consists of mountains, plains, and valleys, natural depression that is 12 km wide; it which influence the climate conditions across extends for 32 km from the border with the the country. Dominican Republic to the coast of the Baie de Port-au-Prince. The mountains of the southern The mountainous northern region and the peninsula extend from the Massif de la Selle in Northern Plain along the northern border with the east to the Massif de la Hotte in the west. the Dominican Republic range in elevation The range’s highest peak — the Morne de la from 600 to 1,100 meters (m). The central Selle — is the highest point in Haiti, rising to region consists of the Central Plateau that an altitude of 2,715 m. The Massif de la Hotte spans 85 kilometers (km) from the southeast varies in elevation from 1,270 m to 2,255 m. a Information is provided for RCP4.5 in Annex B of this report. 7 Moreover, numerous rivers and streams regions of the island, with two pronounced traverse the plains and mountainous areas. peaks occurring between March and November. The largest drainage system in the country The remainder is arid (2.5 percent) — temperate is that of the Artibonite River. Rising from the without a dry season and with a hot summer foothills of the Massif du Nord as the Libón (2.2 percent), or temperate with a dry winter River, the river crosses the border into the and warm summer (1.7 percent). Dominican Republic and then forms part of the border before re-entering Haiti as the The north wind brings fog and drizzle, inter- Artibonite River. The 400-km Artibonite River rupting Haiti’s dry season from November to is only one meter deep during the dry season, January. However, from February to May, the and it may even dry up completely in certain weather is very wet. Northeast trade winds spots. During the wet season, it is more than bring rains during the wet season. Monthly three meters deep and subject to flooding. temperatures typically range from 19°C to 28°C in the winter and from 23°C to 33°C during the summer months (Figure 3). OBSERVED AND PROJECTED CLIMATE AND SEA-LEVEL RISES (SLRS) Northern and windward slopes in the 11. Haiti has a hot and humid tropical climate mountainous regions receive up to three that can be separated into six climate zones. times more precipitation than the leeward The country is predominantly tropical savannah side; annual precipitation in the mountains (55 percent), tropical rainforest (25 percent), averages 1,200 millimeters (mm). In contrast, and tropical monsoon (14 percent). These the annual precipitation in the lowlands is as areas are characterized by high temperatures low as 550 mm; the Plaine du Gonaïves and and precipitation rates. The wet season is the eastern part of the Plaine du Cul-de-Sac long, particularly in the northern and southern are the driest regions in the country. FIGURE 3. Projected average monthly temperatures and precipitation levels in Haiti 120 mm 30 ˚C 29 ˚C 100 mm 28 ˚C 27 ˚C 80 mm 26 ˚C 60 mm 25 ˚C 24 ˚C 40 mm 23 ˚C 22 ˚C 20 mm 21 ˚C 0 mm 20 ˚C Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Historical Ref. Period, 1986-2005 2020-2039 2040-2059 Historical Ref. Period, 1986-2005 2020-2039 2040-2059 Source: World Bank Climate Change Knowledge Portal 8 | Climate and Health Vulnerability Assessment: Haiti 12. There is already evidence of the climate experience the highest increase (0.92°C by changing in Haiti: as Section III of this 2020–2039 and 1.76°C by 2040–2059). The report will show, this situation is leading maximum temperature is projected to reach to significant human health impacts. Annual an average of around 30°C (for both time mean temperatures have steadily increased periods), with the highest average maximum over the past half century. Since 1960, mean temperatures experienced in the Artibonite temperatures have risen by 0.45°C. Much of (31.27°C) and Nord (31.17°C) departments this warming has occurred between June by 2020–2039. Moreover, the increases in and November. Temperatures across Haiti are the number of tropical nights (that is, where fairly uniform: the variation in the subnational temperatures > 20°C), at the national level, annual temperature is only approximately 2°C are also expected to be 31.54 by 2020–2039 on average. The southwestern departments and 51.81 by 2040–2059. of Nippes, Grand’Anse, and Sud experience the warmest temperatures throughout the 15. Precipitation is expected to increase to 632.74 year, while the eastern departments of Centre mm/year (+26.27 mm) by the 2020–2039 and Sud-Est experience the coolest. period, but it will decrease to 588.49 mm/year (–17.97 mm) by the 2040–2059 period. The 13. Precipitation is asymmetrical, due to the month of October will experience the greatest orientation of Haiti’s mountain chains and increase of precipitation (+8.26 mm), while the the rain-bearing northeast trade winds. On greatest decrease (–7.7 mm) will take place a national scale, variations in the average in September during the 2020–2039 period. annual rainfall since the early 1900s have However, by the 2040–2059 period, there will varied by less than 2 mm, with a rising trend be a decrease in precipitation of 18.95 mm recorded over time. Overall, Artibonite (1144 in May. The department of Grand’Anse will mm), Nord-Ouest (1198 mm), and Nord-Est (1220 experience the highest precipitation increase mm) receive the least amount of average annual for the 2020–2039 period. However, all the rainfall, while Sud (1955 mm) and Grand’Anse departments will experience a decrease for (1806 mm) receive the most. The heaviest the 2040–2059 period. rainfall has historically occurred in May for most departments, except for Grand’Anse, 16. Over the past century, the rate of SLRs has Nippes, and Sud-Est; they receive the most roughly tripled in response to the increase in rainfall in October, with the Nord experiencing the global temperature of 0.8°C. SLRs pose a the heaviest rainfall in November. significant threat to islands across the globe, including Hispaniola. Since the 1950s, the 14. The average national temperature will mean SLR in the Caribbean region has been increase by 0.88°C in the 2020–2039 approximately 1.8 mm/year. Historic sea-level period and by 1.7°C in the 2040–2059 data recorded from Haiti are sparse: published period, resulting in average temperatures tide tables from the National Oceanic and of 26.35°C and 27.17°C, respectively. The Atmospheric Administration (NOAA) for the month of September will have significant Port-au-Prince date back to only 2019. The temperature increases for the two time IPCC AR6 in 20212 reported that the mean periods, that is, 1.04°C and 1.81°C, respectively. global sea surface rose by 0.20 m between Sub-nationally, the Nord-Est department will 1901 and 2018 — constituting an average SLR Climatology | 9 FIGURE 4. Total population living below 1 m above the sea level in Haiti, by department Source: Climate Central Risk Finder. 2021. Total population below 1m in Haiti by department. https://riskfinder.climatecentral. org/country/haiti?comparisonType=department&forecastType=BK_RCP85_p50&impact=Population_Worldpop15&level=1&pro- tection=unprotected&unit=m of 1.3 mm/year between 1901 and 1971 and FLOODS 1.9 mm/year during the 1971–2006 period. 19. Floods are the leading factor of vulnerability in Haiti and throughout history. Since 1991, 17. Available information suggests that SLR the country has experienced 34 flood events trends in the Caribbean have been broadly (25 riverine floods, eight flash foods, and one similar to global trends over this same period.3 coastal flood),5 with the most populated cities In Haiti, it is expected that SLRs will increase by 0.21 m (0.17–0.24 m) by the 2030s and by 0.35 — all nestled in valleys along the coast — m (0.30–0.40 m) by the 2050s.4 Considering most affected. Widespread deforestation in the country’s topography, the Artibonite and the upper reaches of these valleys, coupled Ouest departments have a great part of their with the lack of drainage infrastructure, has land below 1 m above the sea level, where created an environment that is conducive around 165,000 Haitians live (see Figure 4). to flooding. When it rains, the steep, often barren, hills surrounding them flush rainwater toward the urban areas. CLIMATE-RELATED HAZARDS Riverine floods have impacted more than 18. Haiti is vulnerable to several extreme 502,910 people, leaving 3,024 lives lost and climate-related events that will be estimated damages of USD2,157,000,6 since exacerbated by ongoing climate change. 1991. Almost all of Haiti’s 30 major watersheds The most common are floods and hurricanes; are of concern, because of intense seasonal but they also include landslides, droughts, and extreme temperatures. The impacts of rainfall, storm surges in the coastal zones, and these hazards are further compounded by a deforestedb and eroded landscape. Given anthropogenic causes, including deforesta- b Haiti is one of the most deforested countries in the world, with forest tion, coastal degradation, and urbanization. cover estimated at just 1.5 percent. 10 | Climate and Health Vulnerability Assessment: Haiti the near-complete absence of embankments and remain similar in the 2050s, at the national and levees, this cycle then intensifies the next level. During the 2030s, the largest increase, round of flooding, leading to the destruction with more risks of flooding, will be in October of crops, farmlands, and agricultural infrastruc- during the wet season (April to October). As ture, as well as losses of livestock and human for the 2050s, there will be a slight decrease lives. On the other hand, coastal and flash in the average largest 1-day precipitation level floods account for approximately 85 percent of (42.35 mm) (see Table 1). Sub-nationally, the flooding cases. Flash floods have also resulted greatest increases will be taking place in the in adverse consequences since 1991 — 120,112 Sud-Est and Ouest departments (+5.59 mm people affected, 98 lives lost, and damages and +5.05 mm for the 2030s, along with +7.24 estimated at USD1,439,000.7 mm and +7.03 mm for the 2050s, respectively). 20. There is high confidence that storm surges On the other hand, projections of the 5-day will increase in tandem with the mean SLRs, cumulative precipitation, where areas can thus leading to more coastal flood hazard8 become saturated over several days, present Haiti’s coastal flood hazard is classified as a different flood risk. There will be an average “medium,” that is, more than a 20 percent increase of 9.68 mm for the 2030s nationally, chance of potentially damaging coastal flood especially during the rainy months, with the waves occurring in the next 10 years.9 Its Grand’Anse department experiencing the riverine and urban flood hazards are classified greatest increase (+20.2 mm). In the case of as “high,” which means that potentially the 2050s, there will be a slight decrease damaging and life-threatening river floods nationally (–2.33 mm), with Nord-Ouest expe- and urban floods are expected to occur at riencing the greatest decrease (–6.69 mm), least once in the next 10 years. Although the while Grand’Anse will experience increases surface flood hazard in urban and rural areas in its average 5-day cumulative rainfall (9.57 is not included in this hazard classification, mm, anomaly). it may also be possible in the coming years. Lastly, while average largest 1-day precip- 21. Extreme precipitation magnitudes are itation (in mm) will increase, the number of projected to increase over the 2030s and consecutive wet days will decrease for the 2050s. The average largest 1-day precipi- 2030s and 2050s (–0.86 mm and –6.62, ta¬tion level will increase slightly to 43.15 respectively). Also, the rainy days are going mm (+1.76 mm) on an annual average by the to be more scattered throughout the seasons. 2030s (compared to the 1986–2005 period) TABLE 1. Projections on precipitation extremes for the 2030s and the 2050s, based on a high-emissions scenario of RCP8.5 2020–2039 2040–2059 Avg largest 5-day cumulative (mm) 116.65 104.64 Avg largest 1-day (mm) 43.15 42.35 Consecutive wet days 71.46 65.7 Source: World Bank Climate Change Knowledge Portal Climatology | 11 HURRICANES convective storm. In 2021, Haiti was ranked 22. Haiti lies in the Caribbean hurricane corridor; third among the countries most affected by thus, it is regularly affected by storm surges extreme weather events in the world.13 (see Figure 5). The country is mainly subject to 23. In 2016, Hurricane Matthew made landfall tropical waves, which tend to be influenced by in Haiti, and subsequently, became one of the intertropical convergence zone and carried from east to west by trade winds. These climate the most destructive hurricanes for Haiti. events can lead to tropical cyclogenesis and The country was subjected to days of intense produce cyclonic systems characterized by precipitation, with the total exceeding 30 inches excessive rainfall and strong winds, resulting in some locales.14 Due to its steep, deforested in the formation of storms: convective storms, terrain, Haiti was vulnerable to floods and at tropical storms, or hurricanes.10 risk of mudslides.15 The intense precipitation resulted in extensive flooding, infrastruc- Haiti’s storm season goes from June through ture damage, crop losses, and significant November, affecting mostly the West and mortality.16,17 The hurricane also led to 600 South departments. Hurricanes constitute deaths, with 2.1 million people impacted,18 the second-most frequent disaster type, including over 50,000 internally displaced.19 representing 40 percent of the country’s Sub-nationally, the hurricane caused consid- total disasters.11 Hurricanes are also highly erable damage to the southern peninsula hazardous, with an approximately 20 percent and the northwestern parts of the country.20 chance of damaging wind speeds.12 From 1991 In particular, the Grand’Anse and Sud — both to 2020, Haiti experienced a total of 35 storms — of which were located in the southwestern 31 hurricanes, three tropical storms, and one tip of Hispaniola — were the most affected. FIGURE 5. Hurricane Matthew’s trajectory in the Caribbean Basin Source: Knapp, K. R., M. C. Kruk, D. H. Levinson, H. J. Diamond, and C. J. Neumann, 2010: The International Best Track Archive for Climate Stewardship (IBTrACS): Unifying tropical cyclone best track data. Bulletin of the American Meteor. Society, 91, 363-376. doi:10.1175/2009BAMS2755.1 12 | Climate and Health Vulnerability Assessment: Haiti 24. Severe hurricanes are projected to increase 26. Landslides are among the climate change- in frequency and severity. Haiti’s geograph- related hazards that Haiti experiences. ical location along the hurricane corridor will Even though landslides are the least frequent worsen the country’s vulnerability under disaster in the country (1 percent of the climate change scenarios. By 2050, rainfall reported natural disaster distribution),27 Haiti’s from hurricanes is expected to increase by geographic location, which places it in the 20–30 percent near the center, and by 10 path of the Atlantic hurricanes, combined with percent in the outer circle of the hurricane (200 the steep topography of its western region km or larger). Wind speeds from hurricanes from which all major river systems flow to the will also increase by 2–11 percent.21 coast, makes the country particularly vulnerable to landslides, especially between June and Although the frequency of Atlantic storms December. Taking into consideration the is projected to decrease, the most severe slope, the slope orientation, the water flows hurricanes from the Atlantic that will make in the land, as well as hillside and geological an incursion into the Caribbean will increase factors, it is observed that most of Haiti has its frequency by 80 percent by the end of a moderate level of landslide susceptibility. the century.22 Cities such as Port-au-Prince and Gonaïves are 2–4 times more vulnerable At the subnational level, the highest levels of to tropical storms than any other city in the landslide susceptibility are in the zones where country.23 Increases in hurricane frequency the mountains are located, especially in the and overall storm intensity will worsen flood southern and southeastern parts of Haiti, due and storm surge risks in the country.24 to the slope factor.28 Port-au-Prince is one of the cities with the highest landslide risk (“very high”), especially its southern part. Also, in LANDSLIDES Léogâne — a city located in the western part 25. High deforestation rates, coupled with of Port-au-Prince, the landslide risk is rated changing rainfall patterns, make landslides as “high” and “very high” (see Figure 6). In commonplace and particularly dangerous in terms of potential damage, highways are steep sloping lands.25 On many Caribbean highly susceptible to landslides, especially in islands, frequent heavy rains, the mountainous the southern part of the country. For example, topography, and the volcanic geology combine the highway that connects Port-au-Prince and to create high-hazard conditions for landslides Léogâne, along with the highway that starts in (see Figure 6). On some slopes, landslides are Port-au-Prince and continues to the eastern common even when rainfall is only mild. The part of the country, are two of the riskiest roads relationship between landslides and climate in the country29 (see Figure 6). change is complex. While changes in rainfall and temperature may lead to more landslides, 27. Projections about extreme precipitation the increasing frequency of droughts, as events suggest that they would be the projected in Haiti, may decrease the likelihood main trigger for future landslides. Increases of these events.26 In Haiti, landslides are in the average largest 1-day precipitation common along all river valleys, where years level for the 2030s indicate that landslides of deforestation have left the upper reaches could occur concomitantly. Projections for of the western basins bare. the 2050s underline a decrease in rainfall, Climatology | 13 FIGURE 6. Risk of landslide hazard Source: Global Facility for Disaster Reduction and Recovery. 2021. Climate Risk and Adaptation Country Profile: Haiti. https://www.gfdrr.org/en/publication/climate-risk-and-adaptation-country-profile-haiti. which could reduce the risk of landslide. At From 1991 to 2020, the country went through the same time, the increased frequency and five drought periods due to irregular and intensity of hurricanes could impact Haiti’s insufficient rainfall, resulting in crop failures, steep topography, resulting in more landslides. food shortages, and therefore, famine. 31 These events tend to appear during the dry season (generally from December to April), DROUGHTS exacerbated by the influence of the El Niño- 28. Haiti is susceptible to droughts due to Southern Oscillation. The five drought events rising temperatures related to climate have affected 8,855,521 people.32 change, deforestation, and limited water management infrastructures. Haiti is affected 29. As rainfall will decrease for the 2050s, by the El Niño-Southern Oscillation — a climatic droughts are expected to become more pattern that generates large-scale anomalies extreme.33 The annual Standardized Precipi- that increases surface temperatures in the tation Evapotranspiration Index (SPEI) drought Pacific Ocean. This climate phenomenon delays index measures drought severity according to the start of the cyclone seasons, as well as its intensity and duration. Negative SPEI values increases the dry season. Departments in indicate a negative water balance, whereby the North-West, Artibonite, North-East, and the −2 value equates to “severe drought.” The Central have experienced repeated droughts annual SPEI drought index values for Haiti (see Figure 7).30 will be −0.42 for the 2030s and −0.68 for the 14 | Climate and Health Vulnerability Assessment: Haiti FIGURE 7. Hazard climate drought zones Source: HaitiData.org. https://haitidata.org/layers/geonode_data:geonode:hti_hazardclimate_droughtzone_polygon_052010. 2050s.34 Although projections do not meet the 31. Although heatwaves in Haiti will remain −2 threshold, droughts would have an even an uncommon climatic event, humidity will greater impact, given Haiti’s vulnerabilities increase the “feel-like” temperature. There in its water management infrastructure and are no reports of heatwaves or the number of agriculture system. “very hot” days to date. Moreover, projections for the 2020–2039 and 2040–2059 periods do not report any number of “very hot” days RISING TEMPERATURES (Tmax > 35°C and > 40°C), under high-emissions 30. Rising temperatures in Haiti are going to scenario RCP8.5.35 However, it is expected be exacerbated by humidity. Whereas the that this extreme temperature will increase previous discussion considered overall historic in frequency from 2041 onwards.36 and projected temperature changes, this section will focus on temperature extremes Furthermore, the number of heat index days defined as “temperatures ≥ 35°C,” using two is expected to increase more drastically in the classifications: (a) “very hot” days: ≥ 35°C; and country. While Haiti will only experience an (b) heat index days of ≥ 35°C. Notably, there increase of 4.8 heat index days by the 2030s, are overlaps between these discussions, given however, the figure will accelerate to 31.42 how high current temperatures are across by the 2050s nationally. It is projected that Haiti and the projections. Grand’Anse will be the hottest department in the country, experiencing 25.25 heat index Climatology | 15 days by the 2030s and 94.01 by the 2050s. occurrences of wildfires.38 The dependence Furthermore, departments — such as Ouest, of rural populations on charcoal, obtained Nord-Ouest, Sud-Est, and Sud — will go from from cutting trees, exposes them to wildfires registering approximately nine heat index days and increases their vulnerability. In areas that for the 2030s to roughly 60 days for the 2050s have wildfire exposure, both duration and (see Table 2). intensity have increased in the past years.39 33. Wildfires in Haiti are likely to increase as a WILDFIRES consequence of deforestation, prolonged dry 32. High temperatures, coupled with the high rate spells, and the increase of high temperatures of deforestation, increase the frequency and related to climate change. It is projected that intensity of wildfires. In Haiti, the probability of these wildfires would increase in duration and weather conditions exacerbating a significant severity.40 However, there are no concrete wildfire is greater than 50 percent.37 The estimations on how frequent and how intense country has only 3 percent of forest cover they would become, or how they would impact remaining at the national level; combined with human health. rising temperatures, this could enable the TABLE 2. Heat index days (> 35°C) anomaly projections, under high-emissions scenario RCP8.5 REGION 2020–2039 2040–2059 Haiti 4.8 31.42 Ouest 9.18 62.64 Grand’Anse 25.25 94.01 Nord Ouest 11.64 60.35 Nippes 1.8 45.04 Nord Est 0.8 7.13 Nord 4.58 41.02 Centre 3.96 28.41 Artibonite 5.64 45.5 Sud Est 9.11 59.28 Sud 8.49 59.01 16 | Climate and Health Vulnerability Assessment: Haiti KEY MESSAGES Historic Observations → Since 1960, mean temperatures have risen by 0.45°C. Much of this warming has occurred between June and November. → Since the early 1900s, the average variations in annual rainfall have varied by less than 2 mm, with a rising trend recorded over time. → The mean SLR rate in the Caribbean has been 1.8 mm/year. Projected Climate → Nationally, mean annual temperatures will increase by 0.88°C by the 2030s and 1.7°C by the 2050s. → Annual precipitation will increase by 26.27 mm by 2030, but will decline by 17.97 mm in the 2050s. → SLRs are expected to increase by 0.21 m by the 2030s and 0.35 m by the 2050s. Climate Hazards → Floods: Flooding is the leading factor of vulnerability in Haiti. Since 1991, the country has experienced 34 flood events. Extreme precipitation is expected to increase by the 2030s. → Hurricanes: Haiti is highly vulnerable to storms, as it is geographically located along the hurricane corridor in the Caribbean. Although the frequency of the Atlantic storms is projected to decrease, the most severe hurricanes will increase their frequency by 80 percent by the end of the century. → Landslides: Haiti’s geographic location in the path of Atlantic hurricanes, combined with the steep topography of its western region from which all major river systems flow to the coast, makes the country particularly vulnerable to landslides, especially between June and December. → Droughts: From 1991 to 2020, the country went through five drought periods due to insufficient rainfall, thereby resulting in crop failures, food shortages, and consequently, famine. Dry periods are expected to increase. The North-West, North-East, Artibonite, and West departments are more at risk of droughts. → Rising temperatures: The frequency of hot days and hot nights increased by 63 and 48 days per year, respectively, between 1960 and 2003. Tropical nights and heat index days are expected to increase considerably for the 2030s and 2050s. → High temperatures and the high rates of deforestation have increased the frequency and intensity of wildfires. Climatology | 17 SECTION III. CLIMATE-RELATED HEALTH RISKS 34. Climate change influences human health outcomes and disease in innumera- ble ways. This section reviews evidence for the burden of current climate-related health risks in Haiti and projections of future risks of health outcomes due to climate change, based on the expected changes in the country’s climate under RCP8.5. The health risks are presented according to prioritization and are examined according to historic, current, and projected risks, where information is available. The risks to Haiti’s health system, in relation to climate change, are covered in Section IV. 35. Haiti is experiencing a double disease burden: (HIV) / acquired immunodeficiency syndrome the proportion of communicable diseases is (AIDS) (5.3 percent); neonatal disorders (9.3 declining, while the proportion of noncom- percent); diabetes mellitus (3.13 percent); municable diseases (NCDs) is increasing. diarrheal diseases (5.59 percent); birth defects This is important, since many communicable (5.4 percent); acts of interpersonal violence diseases and NCDs are climate-sensitive (3.51 percent); and chronic renal failure (1.57 and will, therefore, interact with the overall percent).42,43 climate-related burden of disease. Mental health and well-being are also important Of the 10 highest causes of death, HIV/AIDS in the consideration of the climate-related showed the largest decrease, falling by burden of disease. 43.6 percent from 2009 to 2019, followed by diarrheal diseases (15.6 percent). These Although the causes of mortality are poorly 2009–2019 changes in health outcomes documented in Haiti,41 the Haiti Health Plan suggest that the population is experiencing uses the listing from the  Institute for Health an epidemiological transition: mortality and Metrics and Evaluation  (IHME) in setting morbidity caused by communicable, maternal, out the 10 leading causes of death in the neonatal, and nutritional diseases (28.7 country. In 2019, they are ischemic heart percent) and injuries (13 percent in 2016 and disease (4.56 percent of the total disability 9.3 percent in 2019) had declined, while NCDs adjusted life years [DALYS] c); stroke (4.6 had increased proportionally (57 percent in percent); lower respiratory tract infections 2016 compared to 61.9 percent in 2019) (see (6.32 percent); human immunodeficiency virus Figure 8).44 The disease burden attributed to NCDs (cardio- c One DALY represents the loss of the equivalent of one year of full health. DALYs for a disease or health condition are the sum of the years vascular diseases [CVDs], cancers, congenital of life lost due to premature mortality (YLLs) and the years lived with a disability (YLDs), due to the prevalent cases of the disease or health defects, stroke, and diabetes) is caused by condition in a population. Source: Disability-adjusted life years (DALYS) (who.int). multiple contributing factors. However, the 19 FIGURE 8. Top 10 causes of total number of deaths in 2019 and percentage change, 2009–2019, all ages combined Communicable, maternal, neonatal and nutritional diseases Non-communicable disease Injuries 2009 2019 % change, 2009-2019 HIV/AIDS 1 1 Ischemic heart disease 26.09% Ischemic heart disease 2 2 Stroke 20.9% Stroke 3 3 Lower respiratory infect -4.8% Lower respiratory infect 4 4 HIV/AIDS -43.6% Neonatal disorders 5 5 Neonatal disorders 4.8% Diarrheal diseases 6 6 Diabetes 22.6% Diabetes 7 7 Diarrheal diseases -15.6% Congenital defects 8 8 Congenital defects 5.8% Interpersonal violence 9 9 Interpersonal violence 22.6% Chronic kidney disease 10 10 Chronic kidney disease 30.3% Source: Estimates generated by IHME and downloaded from http://www.healthdata.org/haiti. link with climate change is clear. Increasing health more broadly.46 Further, climate may heat and drought conditions leads to the exacerbate existing health inequalities, decreased yield and nutrient quality of crops, affecting particularly vulnerable groups such as thus resulting in malnutrition. Poor air quality the elderly; women and young children; those is caused by an increase in wildfires, as well living with pre-existing conditions and disabil- as the continued burning of fossils and other ities; as well as groups in poverty, including household fuels. NCDs can also arise from a those occupying informal urban settlements, synergistic combination of multiple risk factors. along with displaced and rural populations. In 2019, the three risk factors that account 37. Haiti suffers from extreme weather events for the highest NCD burden in Haiti are (a) such as storms, floods, droughts, and malnutrition, (b) air pollution, and (c) high blood wildfires. Due to its location within the pressure, respectively. All three have links to hurricane basin, Haiti had been adversely climate change, with pathophysiological links affected by storms Jeanne (2004), Matthew to CVDs (including hypertension) becoming (2016), and Hanna (2018) — all of which resulted better characterized.45 The risk factors for in fatalities.47 In the period between 1991 and the total burden of diseases (communicable 2020, 4,803,699 people were affected by diseases, NCDs, and injuries) are presented storms, with 5,753 deaths recorded (see Figure 9, with the majority being impacted by Table 3). climate change. Direct impacts, such as injuries due to 36. Exposure to health risks from climate change climate-related events, represent 1.34 percent are inequitably distributed within and across of the total DALYs in the country.48 Tropical populations. Factors that affect vulnerability storms disproportionately impact those living to climate are often similar to those that affect in flood zones and coastal areas.49 During 20 | Climate and Health Vulnerability Assessment: Haiti FIGURE 9. Top 10 risks contributing to the total number of DALYs in 2019 and percent change, 2009–2019 — all ages combined Metabolic risks Environmental/occupational risks Behavioral risks 2009 2019 % change, 2009-2019 Malnutrition 1 1 Malnutrition -8.4% Air pollution 2 2 Air pollution 0.7% WaSH 3 3 High blood pressure 30.4% Unsafe sex 4 4 High fasting plasma glucose 33.9% High blood pressure 5 5 WaSH -14.8% High fasting plasma glucose 6 6 Dietary risks 27.6% Dietary risks 7 7 Unsafe sex -32.3% High body-mass index 8 8 High body-mass index 41.6% Alcohol use 9 9 Alcohol use 27.2% Tobacco 10 10 High LDL 30.1% High LDL 11 12 Tobacco 8.9% Source: IHME, http://www.healthdata.org/haiti. TABLE 3. Flood and storm events in Haiti from 1991 to 2020 EXTREME EVENTS SUBTYPE EVENTS COUNT TOTAL DEATHS TOTAL AFFECTED POPULATION Floods Total 46 3,208 723,748 Coastal Flood 1 0 4,690 Flash Floods 8 98 115,422 Riverine Floods 25 3,024 502,910 Floods (Uncategorized) 12 86 100,726 Storms Total 35 5753 4,803,699 Source: Em-Dat. The database is made up of information from various sources, including UN agencies, NGOs, insurance companies, research institutes, and press agencies. Priority is given to data from UN agencies, governments, and the International Federation of Red Cross and Red Crescent Societies. EM-DAT includes all disasters from 1900 until the present, conforming to at least one of the following criteria: (a) 10 or more people dead; (b) 100 or more people affected; (c) the declaration of a state of emergency, and / or (d) a call for international assistance. the 1985–2018 period, floods were the hospitals and health centers51 (see Table 3). most frequent natural hazard in Haiti (47.58 The capital city of Port-au-Prince is particularly percent).50 For example, in 2004, intense vulnerable to flooding, with a large portion of precipitation resulted in two major floods its inhabitants residing on flood plains in poorly with more than 2,700 fatalities, affecting more constructed housing.52 than 300,000 persons and severely damaging Climate-Related Health Risks | 21 38. Extreme weather events, such as storm CHVA examines climate and nutrition linkages surges, floods, and wildfires, are expected through a food security lens in Haiti, as it to become more frequent and intense. They relates to the weather and climate impacts can act as a force multiplier: for example, on agricultural productivity. Agricultural flooding causes soil erosion, which leads to productivity — a key determinant of food avail- decreased crop productivity and livestock, ability — is affected by weather and climate and, in turn, malnutrition. This is just one in a multitude of ways: such events ranging example of a synergistic interaction causing from short-term shocks (for example, natural climate-related health risks.53 disasters) to longer term changes in agroeco- logical conditions can drastically reduce yields 39. Haiti’s CHVA assesses six climate-related or redefine the spatio-temporal patterns of health risk categories. They include nutrition crop suitability. risks, waterborne and water-related diseases, vector-borne diseases (VBDs), heat-related 41. The level of chronic food insecurity in Haiti morbidity and mortality, air quality health is among the highest in the world. Nearly risks, as well as mental health and well-being. half of the population (44 percent: 4.3 million Each category is assessed, in terms of current people) face acute food insecurity, with the and future risks, with considerations for both prevalence of undernourishment among 46.8 distinctive national and subnational features, percent of the population for the 2018–2020 where possible. It is important to note that period.56 The main causes of food insecurity these categories represent only the most and malnutrition in Haiti include low agricul- pressing health risks to the population in Haiti. tural productivity, economic decline, limited access to clean water and sanitation, poverty, and political instability.57 NUTRITION RISKS 40. Weather and climate are the foundational Agricultural productivity has languished in drivers of healthy and sustainable diets. The response to (a) recurrent natural disasters mechanisms by which climate change affects unrelated to climate (for example, earthquakes), nutrition via the food system are profound; (b) extreme weather events (for example, they include acute and chronic effects on storms, flooding, landslides, and droughts), (c) agricultural production, storage, processing, high levels of environmental degradation, (d) distribution, and consumption (see Figure the heavy reliance on rainfed agriculture, and 10). Nutritionally secure and stable diets not (e) limited access to information and modern only depend on agricultural production, but farm technologies.58 Agriculture employs half also on the complex interactions of demand, of Haiti’s total employment, with most farmers economics, legislation, conflict, food waste, operating small (< 2 hectares [ha]) rainfed nutrient losses, food safety, and access.54 subsistence farms59 that are highly vulnerable Climate variability is already contributing to to climate stresses and shocks, such as the increases in global hunger and malnutrition.55 El Niño / La Niña phenomenon, which have increased the duration of dry spells.60 While a comprehensive analysis of the climate change’s impact on the food system 42. As of 2018, 21.9 percent of children under is beyond the scope of this assessment, this five years old in Haiti were estimated to be 22 | Climate and Health Vulnerability Assessment: Haiti FIGURE 10. Stages of the food system that drive healthy and sustainable diets Healthy & Sustainable Diet Agriculture Storage Processing Distribution Consumption Production Unhealthy & Climate Change Post-harvest Loss Nutrient Losses Demand Culture Unsustainable Diet Land Use Mycotoxins Fortification Trade A ordable Water Use Nutrient Losses Waste Politics Accessible Waste Waste Legislation Economics Preferences Extreme Weather Nutrient Losses Nutrient Losses Legislation & Policies Waste Waste Source: Macdiarmid and Whybrow 2019. stunted and 3.7 percent wasted, with the 2022. The populations were mostly living child mortality rate recorded at 8.3 percent. in areas in the Centre, Nord-Ouest, and Sub-nationally, the Centre department had Sud-Ouest departments; while 33 percent the highest prevalence of stunting (30.1 of the population (approximately 2,995,664), percent), while Artibonite had the highest classified under “crisis” (IPC phase 3e), was child wasting rate (4.3 percent) and the Ouest distributed throughout the national territory department had the highest child mortality (see Figure 11). rate (11.2 percent) (see Table 4). 43. Haitians’ diets are characterized by poor According to the Integrated Food Security quality and limited diversity. Their diet is Phase Classification (IPC) phases of severity based on rice, maize, wheat, and sorghum, for acute food insecurity, 14 percent of the which is lacking in terms of foods rich in country’s population was classified under proteins such as fish, meat, dairy, or eggs.61 “emergency” (IPC Phase 4d) as of the reporting Furthermore, rice consumption is dependent period from September 2021–February on imports, which have increased since the 1980s.62 Nutritional concerns are linked to d IPC Phase 4: Households either have large food consumption gaps, reflected in very high acute malnutrition and excess mortality, or are able to mitigate large food consumption gaps, but only by employing e IPC Phase 3: Households either have food consumption gaps, reflected emergency livelihood strategies and liquidating assets. [[I had to by high or above-usual acute malnutrition, or are marginally able to “Accept Changes” here, because Word seems to be buggy with meet minimum food needs, but only by depleting essential livelihood footnotes]] assets or through crisis-coping strategies. Climate-Related Health Risks | 23 TABLE 4. Child stunting, wasting, and mortality rates, by department CHILD STUNTING (%) CHILD WASTING (%) CHILD MORTALITY (%) Aire Métropolitaine 20.2 5.9 8.9 Ouest 22.5 3.6 11.2 Sud-Est 20 2.5 7.6 Nord 20 3.6 5.4 Nord-Est 21 1.5 7.7 Artibonite 22.4 4.3 8.4 Centre 30.1 2.9 9 Sud 22 2.9 6.2 Grand’Anse 21.6 3.4 5.3 Nord-Ouest 20.3 2.4 5.8 Nippes 17.2 3.6 9 Total 21.9 3.7 8.3 Source: Global Hunger Index. 2019. Haiti: A closer look at hunger and undernutrition. https://www.globalhungerindex.org/ case-studies/2019-haiti.html FIGURE 11. Acute food insecurity, Sept 2021 (Rural + Urban) Source: Integrated Food Security Phase Classification (IPC). Disclaimer: The information shown on this map does not imply that the IPC and CH officially recognize or endorse physical and political boundaries. 24 | Climate and Health Vulnerability Assessment: Haiti periods of the agricultural year when food is resources and, therefore, on food security less available, namely April–June.63 for both the 2030s and the 2050s. The scarcity of water — pivotal for agriculture and 44. The exodus of the rural population to livestock —is classified as a medium-level cities and abroad, and a lack of agricul- hazard in Haiti.67 This means that there is up tural development, have also reduced food to a 20 percent chance that a drought still crops. The country’s food imports — valued occurs in the coming 10 years. Although rice at USD1.05 billion by 2020 — rose by 21.2 is not projected to be as impacted by climate percent from 2019. In particular, 80 percent change as other crops,68 water scarcity and of rice — an important food for Haitians — is water management in Haiti could increase imported. Other products, such as wheat, are food insecurity in the country. Although the also reliant on imports, as domestic production drought index is projected to be mild, the does not meet demand.64 increased intensity of hurricanes and the overall decrease in precipitation, coupled with an The country’s dependency on food imports inadequate water management infrastructure, increases the vulnerability of its food systems. the lack of development in the agricultural If supply countries are dealing with climate sector, and a dependency on food imports, shock impacts in their crop production, they will increase the country’s vulnerability to may not be able or willing to cater to Haiti’s food insecurity. import needs. Moreover, regarding food afford- ability, the continued depreciation of Haitian currency, exchange rates, and the increased WATERBORNE AND cost of public transportation due to fuel prices have also increased the vulnerability of poor WATER-RELATED DISEASES Haitians primarily, as they cannot buy food for 47. Waterborne and water-related risks are their households.65 prevalent in Haiti. This is a consequence of intense precipitation and drought 45. Droughts, soil erosion, reduced water supply, conditions, coupled with inadequate water and increased crop damage have worsened and sanitation systems. Climate change food insecurity. Increased extreme rainfall can cause the re-emergence of waterborne triggers soil erosion and reduces soil fertility, infectious diseases, as well as increase the aggravated by prolonged drought periods. persistence and virulence of pathogens.69 Soil erosion is also worsened by deforesta- The tropical climate creates sudden, extreme tion rates in Haiti. Moreover, as droughts are weather events, such as hurricanes and expected to increase their duration and 92 intense precipitation, with flash flooding in percent of Haiti’s agriculture is rainfed, this urban areas, resulting in the mixing of sewage will lead to a reduction of crop yield.66 with fresh water and consequent waterborne disease (WBD) outbreaks. The construction of 46. Considering the projected decline of rainfall homes on hill tops and deforestation results previously reported and an increase in the in landslides, as well as the buildup of waste drought index, this would have important in drains and culverts, causing multiplier risks consequences on the replenishment of and outcome challenges. soil moisture and the availability of water Climate-Related Health Risks | 25 48. The population of Haiti is already vulnerable introduced by responders from overseas. to waterborne and water-related diseases Cholera became endemic from 2010 to 2018, which may increase in response to the resulting in approximately 819,000 reported changing climate. Haiti has the highest cases and 9,786 deaths.77 Contamination of mortality rate for enteric diseases for all ages the Meye tributary system of the Artibonite — both male and female (33.11 per 100,000 River, the poor sanitation services and the inhabitants) in the Latin America and the poor treatment of drinking water accelerated Caribbean (LAC) region and the western the epidemic, which then made the disease hemisphere70 (see Figure 12). This is related to endemic.78 The graph below shows the spike in its poor water, sanitation, and hygiene (WaSH) enteric infections at the time of the earthquake, infrastructure. Sixteen percent of the deaths with Haiti having the highest rates in the LAC of children under the age of five is directly region (Figure 12). No cholera cases had been related to WBDs71 such as cholera.72 Water reported since 2019, and Haiti was declared and sanitation systems in Haiti are already free of cholera in February 2022.79 fragile, leaving the population vulnerable to the transmission of diseases such as cholera, Communities on the coast my also be diarrhea, dysentery, hepatitis A, and typhoid. exposed to increased risk of toxic algal In low-income countries, changes in climate blooms under a warming climate. These are expected to influence diarrhea rates;73 blooms are formed by dinoflagellates, which however, the extent will vary depending on can result in paralytic and neurotoxic shellfish climate change scenarios and local factors.74 poisoning, as well as ciguatera fish poisoning (CFP). The LAC region experienced 7,800 49. Extreme climate-related events in Haiti, such incidents of human intoxication between as hurricanes and floods, have increased the 1970 and 2007, including 119 fatalities mainly incidence of WBDs. 75 Hurricane Matthew in associated with paralytic shellfish poisoning October 2016 resulted in increases in WBDs, (PSP) along the Atlantic and Pacific coasts, and notably, a significant outbreak of cholera,76 and CFP in the Caribbean zone.80 Shellfish FIGURE 12. Enteric infections deaths per 100,000 in the LAC region 150 Haiti 100 50 0 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 Source: IHME. 26 | Climate and Health Vulnerability Assessment: Haiti and fish are important sources of protein in microclimates, the availability of larval sites, Haiti, particularly for coastal communities, the shade for resting, the sources of blood thus making their contamination particularly meals and nectar, and predator density.87 devastating. These algal blooms can flourish in both coastal waters and inland fresh water This assessment focuses on mosquito-borne sources, with growth stimulated by increasing VBDs, including malaria, dengue, chikungunya, temperatures.81 The Great South coastal areas and Zika, due to their significant impact on Haiti. are most affected, with significant concern Other known mosquito-borne VBDs in Haiti reported in the communities of St Jean du include yellow fever and the West Nile virus Sud, Les Cayes, St Louis du Sud, Côtes de Fer, fever. Likewise, other VBDs present in Haiti are Jacmel, Cayes Jacmel, and Marigot.82 lymphatic filariasis and leishmaniasis. Spatial models were constructed to demonstrate the 50. Climate change has resulted in sargassum plausible spatial distributions of the Anopheles inundation on beaches. Concerns in the region (An.) vectors of malaria and the Aedes (Ae.) began in 2011, with the Ministère de L’Envi- vectors of dengue, chikungunya, and Zika to ronnement (MDE) in Haiti drawing attention assess the risk propensity of these diseases. to the issue since 2015.83 When sargassum decomposes, it produces hydrogen sulfide The results of these analyses should be taken — a gas that causes adverse cardiovascular as conservative estimates of the areas of Haiti and respiratory impacts, irritation to the upper that exhibit suitable conditions for vector airways and eyes, as well as neurobehavioral breeding and suitable conditions for vector effects and symptoms.84 Additional concerns breeding where humans are present (that include carcinogenic properties and the health is, populated areas). The time frames under risks associated with the accumulation of heavy consideration are the historical reference metals, particularly arsenic and cadmium, in period (1986–2005), the 2030s, and 2050s sargassum, although the evidence has yet to match the data presented in Section II to be fully established.85 of this assessment. For further information on modeling methodology and inputs, see Annex A. VECTOR-BORNE DISEASES (VBDS) 51. Weather and climate are critical drivers of MALARIA spatio-temporal VBD distribution and trans- 52. Despite nearly achieving the elimination mission dynamics.f At large scales, climate of malaria in the 1960s,88 malaria remains variability causes vector and host ranges to an ongoing public health problem in Haiti, expand or contract, shifting the disease distri- especially among the populations of Ouest, bution and seasonality, and / or facilitating Grand’Anse, Artibonite, and Sud (Table 5). emergence or re-emergence of VBDs.86 At After a surge in cases in the 1970s, more local scales, vector abundance is a product of recent efforts have resulted in the number f The main endemic insect vectors of infectious diseases in Haiti are of malaria cases falling from 30,000 cases as follows: Ae. mosquitoes — vectors of dengue, chikungunya, Zika, and yellow fever; An. albimanus — the primary mosquito carrying in 2012 to 10,000 in 2019.89 In 2019, malaria the malaria parasites; Culex mosquitoes carrying the West Nile virus contributed to 0.46 percent of total deaths, fever and lymphatic filariasis; and Phlebotomas sandfly transmitting Leishmaniasis. with mortality reported as ranging from 5–19 Climate-Related Health Risks | 27 per annum over the 2010–2020 period,90 and Sud-Est, Ouest, and Nippes departments. constituting 0.45 percent of the total DALYs.91 Throughout much of the country, projected The incidence rate is now approximately 1,278 temperature increases will not exceed the per 100,000, with the highest rates of transmis- thermal tolerance of malaria vectors. Likewise, sion occurring after the rainy seasons of March the minimum temperatures are already high to May and October to November,92 in the enough to support the malaria species survival. rural Grand’Anse department,93 although other Range expansion is not projected to occur sources suggest that the Ouest department according to this analysis; however, the overall has 49 percent of the cases.94 suitable area will decline by 2.9 percent (35 square kilometers [km²]), 2.7 percent (134 km²), The primary vectors of malaria in Haiti are An. and 6.2 percent (126 km²), in Nippes, Ouest, albimanus and An. pseudopunctipennis.95 and Sud-Est, respectively. These changes will Female An. albimanus and An. pseudopuncti- likely place nearly 100,000 fewer people at pennis mosquitos will feed on both human and risk of malaria transmission. animals, but with some inconsistent biting and resting behaviors demonstrated across their Changes to the geography of the malaria risk range; they utilize both indoor and outdoor in Haiti through the mid-century are most likely resting sites. Notably, An. pseudopunctipennis to be attributable to human modifications of mosquitoes have broad thermal tolerance, the landscape (that is, land use and land cover ranging from 12°C–36°C, which has enabled [LULC] change) that facilitate vector breeding the survival of the species across most of the and population increases, along with the Americas and throughout Haiti. adoption of malaria prevention, treatment, and control strategies. Notably, the opportunity 53. The malaria transmission risk in Haiti will to eliminate malaria on Hispaniola Island largely remain unchanged through the (comprising both Haiti and the Dominican mid-century, but will decline within the Republic) is being considered again.96 TABLE 5. Number of malaria cases in Haiti in 2014, by geographic department DEPARTMENT NUMBER OF CASES PERCENTAGE Ouest 8,406 49% Grand’Anse 2,143 13% Artibonite 1,944 11% Sud 1,367 8% Nord-Ouest 940 5% Nord 936 5% Centre 535 3% Nord-Est 297 2% Sud-Est 367 2% Nippes 159 1% TOTAL 17,094 Source: Malaria elimination in Haiti by the year 2020: an achievable goal? | Malaria Journal | Full Text (biomedcentral.com) 28 | Climate and Health Vulnerability Assessment: Haiti TABLE 6. Current and projected suitable areas for malaria vectors, by department DEPT, PROPORTION OF REGION BY AREA VULNERABLE SUITABLE FOR MALARIA VECTORS POPULATION POPULATED, OVERALL ABSOLUTE DELTA SUITABLE SUITABILITY VALUES (REF. PERIOD) DEPT. REF. 2030s 2050s REF. 2030s 2050s REF. PERIOD 2030s 2050S 2030s 2050s PERIOD (%) (%) PERIOD (%) (%) (%) (%) Artibonite 32.4 32.4 32.4 96.8 96.8 96.8 930,337 930,337 930,337 0 0 Centre 18.6 18.6 18.6 98.9 98.9 98.9 486,842 486,842 486,842 0 0 Grand’Anse 16.1 16.1 16.1 68.4 68.4 68.4 295,563 295,563 295,563 0 0 Nippes 39.8 39.8 39.5 85.5 85.5 82.6 243,396 243,396 237,277 0 6,119 Nord 38.1 38.1 38.1 84.6 84.6 84.6 456,287 456,287 456,287 0 0 Nord-Est 36.7 36.70 36.7 97.1 97.1 97.1 135,350 135,350 135,350 0 0 Nord-Ouest 16.7 16.7 16.7 92.7 92.7 92.7 412,288 412,288 412,288 0 0 Ouest 39.5 39.5 38.0 88.3 88.3 85.6 1,064,656 1,064,656 1,027,143 0 37,513 Sud 44.5 44.5 44.5 91.3 91.3 91.3 556,056 556,056 556,056 0 0 Sud-Est 32.1 30.7 29.9 95.4 92.0 89.2 443,699 415,885 394,101 27,814 49,598 TOTAL 5,024,474 4,996,660 4,931,244 27,814 93,230 Note: The table above was developed by the authors using data from various sources. See Annex A. FIGURE 13. Geographic and temporal distribution of malaria vectors Note: The maps above were developed by the authors using data from various sources. See Annex A. Climate-Related Health Risks | 29 DENGUE suitable areas largely located within population 54. Despite an absence of routine systematic centers across the country. Ae. Mosquitoes, surveillance data, dengue is considered to which transmit dengue, prefer biting humans be endemic in Haiti, as it is in the Dominican over animals; they are commonly found in Republic.97 A study from 2011 demonstrated urban and peri-urban environments. Notably, the high prevalence of antibodies against projected increases in maximum tempera- dengue virus in all age groups — with 65 tures through the mid-century will not be percent of three-year-olds already having high enough to reduce the overall suitable antibodies from exposure to the virus, as area for dengue mosquito-vector species. well as evidence of hyperendemic trans- Likewise, minimum temperatures are already mission in the western and southeastern high enough throughout the county to enable departments of Haiti.98 Dengue is transmitted vector development and survival. by the bite of infected Ae. aegypti and, to a lesser extent, Ae. albopictus mosquitoes. Over Very likely, the geography of dengue vectors the 2004–2014 period, the number of cases throughout the country will be determined of dengue and the severity of dengue virus by changes in LULC driven by population infections have increased in the Americas, expansion. Haiti’s population is projected to including the Caribbean. reach by 2050 (Figure 14), which will create opportunities for vector-breeding sites, as 55. Over seven million people in Haiti are new commercial and residential areas are vulnerable to dengue transmission, with developed in the absence of coordinated the populations of Ouest and Artibonite at vector control measures. Importantly, while highest risk. The suitability for dengue vectors the findings of this analysis are meant to in Haiti has a distinctly spatial character, with support dengue control measures, results TABLE 7. Vulnerable populations and areas suitable for malaria vectors DEPARTMENT PROPORTION OF REGION BY AREA SUITABLE FOR VULNERABLE POPULATION MALARIA VECTORS DEPARTMENT POPULATED, SUITABLE (%) OVERALL SUITABILITY (%) ABSOLUTE VALUES Artibonite 20.86 53.15 1,341,806 Centre 9.08 48.31 524,797 Grand’Anse 2.86 13.95 134,964 Nippes 11.61 23.78 126,475 Nord 15.25 28.84 657,881 Nord-Est 8.70 27.76 248,906 Nord-Ouest 9.88 51.03 382,814 Ouest 29.55 52.84 3,502,638 Sud 22.28 47.53 428,487 Sud Est 18.56 50.83 359,140 Total 7,707,908 Note: The table above was developed by the authors using data from various sources. See Annex A. 30 | Climate and Health Vulnerability Assessment: Haiti FIGURE 14. Spatial and temporal distribution of dengue vectors Note: The map above was developed by the authors using data from various sources. See Annex A. may be extrapolated to assist in curtailing Ae. genus mosquito. The disease was only chikungunya and Zika risks as well, given that identified in 2015, originally in Brazil, due to these diseases are vectored by the same Ae. the unusually high incidence of congenital mosquito species. microcephaly, which can result in adverse fetal outcomes and neurological conditions 56. Chikungunya is caused by an arbovirus: it is in adults.101 transmitted to humans through the bite of a mosquito of the genus, Aedes (Ae.), mainly 58. The Zika disease spread through the Americas Ae. aegypti. Cases of chikungunya were first to the Caribbean including Haiti, and was diagnosed in Haiti in 2014, when the Ministère declared a public health emergency of de la Santé Publique et la Population (MSPP or international concern by WHO in February the Ministry of Public Health and Population) 2016.102 During the emergence period of the reported a cumulative total of 39,343 cases disease — October 12, 2015 to Sept 10, 2016, between May 31 and June 16, 2014 in the MSPP reported 3,036 suspected cases of 10 departments; the infection rate for Ouest infection in the general population, with 22 was 67 percent.99 Today, the incidence rate is suspected cases of the Zika virus disease reported to be 627 per 100,000 population.100 in pregnant women, 13 suspected cases of the Guillain-Barré syndrome (GBS), and 57. Zika is caused by the flavivirus, which is 29 suspected cases of Zika virus-associ- transmitted through the bite of an infected ated congenital microcephaly. The National Climate-Related Health Risks | 31 Laboratory tested 294 specimens and found affected, which can, in turn, result in acute that 6.5 percent were positive.103 It is reported exacerbations of chronic respiratory and that the surveillance program in Haiti needs cardiovascular conditions.108 to be strengthened to better monitor the evolution of Zika disease in Haiti.104 Further, although there is no evidence of heatwaves as a major hazard for health in Haiti, 59. Despite the strong correlation between VBD the incremental increases in mean tempera- vectors and climate factors, climate is merely tures and the number of heat index days and one determinant in the VBD transmission tropical nights, along with the increase in the risk. The future risk of these diseases will frequency of heatwaves predicted, during depend on the changing climate conditions the 2041–2060 period under high-emissions that define vector suitability, as well as envi- scenario RCP8.5,109 combine to present an ronmental, social, and economic conditions. increasing health risk for the population in Haiti. For example, it is estimated that 3.1 per 100,000 under five years old are currently at HEAT-RELATED MORBIDITY risk of mortality due to high temperatures,g with DALYs at 108.11 per 100,000.110 AND MORTALITY 60. The health risks associated with heat include 62. Extreme heat also has an impact on mental acute mortality; heat-related morbidity health and well-being.111,112 High temperatures such as heat rash, cramps, exhaustion, can aggravate mental health symptoms, as dehydration; and the acute exacerbation of well as increase the risks of suicide113 and pre-existing conditions such as respiratory conflicts.114 More generally, research has shown and CVDs;105 individuals on medications are that hot nights are associated with insomnia,115 at further risk of detrimental interactions. with consequences including susceptibility There are no specific data on the impacts of to diseases and chronic illnesses,116,117 as well heat on health in Haiti, nor are there clear as adverse impacts on psychological and projections. However, the impact of humidity, cognitive functioning.118,119,120 which can be high in Haiti, exacerbates the impacts of heat on health and well-being; 63. Heat is an occupational health risk. There this measure and projection are captured by is a lack of reporting on heat-related injuries, the “heat index” reported in the climatology illnesses, and deaths amongst occupations section of this assessment. in Haiti. Nonetheless, studies from other countries indicate that workers in agriculture 61. Heat-related morbidity and mortality creates and construction are at a particularly high risk pressure on the healthcare system.106 Heat of occupational heat stress.121 Climate-based strokes, which can be described as the core indices can be used to quantify workdays lost body temperature exceeding 40°C (104°F) to extreme heat, reflecting recommended heat and leading to a central nervous system strain thresholds.122 Furthermore, studies on dysfunction, is perhaps the most dangerous heat-related illness, as it can result in severe g “High” temperature is defined as a daily mean temperature that is morbidity and mortality.107 When high tempera- warmer than the theoretical minimum risk exposure level value (TMREL) — the temperature with the minimum level of mortality for all included tures interact with air quality, the levels of causes. The population-weighted mean TMREL is 25.6°C, with a range of 21.3–26.6°C. High temperature — Level 3 risk | Institute for Health ozone, pollutants, and aeroallergens are Metrics and Evaluation (healthdata.org). 32 | Climate and Health Vulnerability Assessment: Haiti age-specific heat-related mortality indicate formation, while heat and droughts increase that heat-related mortality is high in adults in wildfire risks — all of which can result in Haiti, compared with temperate or middle- severe health impacts through inhalation. income countries where heat-related mortality Specifically, changes in wind patterns and is only apparent in the older age groups (over increased desertification increase the 65 years old). long-range transport of air pollutants. Under certain atmospheric circulation conditions, the transport of pollutants — including aerosols, AIR QUALITY HEALTH RISKS carbon monoxide, ozone, desert dust, mold spores, and pesticides — may occur over large 64. Global mortality, driven by the fossil fuel distances and over timescales typically of 4–6 components of PM2.5, is estimated at 10.2 days, leading to adverse health impacts.125 million per year.123 Smoke from wildfires, Available data indicates that Port-au-Prince dust storms, and other air pollutants can and Cap-Haïtien are areas that are the most affect health acutely, as well as contribute affected. to the development of severe chronic health conditions due to fine particulate matter (PM2.5) 66. In Haiti, mortality from particulate air pollution and other toxins. Health impacts include the was responsible for about 14.05 percent of increased risk of respiratory infections, lung all-cause mortality.126 The combined health cancer, COPDs, exacerbations of asthma, CVDs, impact of household exposures to particulate and the advancement of dementia. Reducing air pollution from the inadequate combustion fossil fuel usage has the clear co-benefits of of solid cooking fuels, plus general ambient producing both desired climate and health pollution, was about 5,840 DALYS per 100,000 outcomes.124 Those who are particularly annually during the 2009–2019 period.127 Over vulnerable to particulate air pollutants include the 2009–2019 period, air pollution was the those with known asthma, chronic obstructive second-highest contributor to DALYS in Haiti pulmonary diseases (COPDs), children. Ground- across all age groups, second only to malnu- level ozone affects lung functioning, impacting trition.128 Haiti’s annual mean concentrations individuals with asthma in particular, and can are 19.0 micrograms per cubic meter (µg/ lead to premature mortality. In densely built-up m3)h for PM2.5 and 76.44 µg/m3 (39 parts per population areas, rising temperatures can billion [ppb]i) for ozone in 2019.129 These values result in “smog-heat island” effects; smog also exceed the WHO recommended maximum of forms where air stagnates, for example, in 5 µg/m3 for PM2.5 and 60 µg/m3 for ozone. low-lying regions. Other contributors to poor air quality in Haiti include power generation, Since 1990, the population-weighted diesel generators, and waste burning — all concentrations of both ambient particulate of which contribute as a positive feedback matter and ambient ozone pollution in Haiti mechanism to climate-related health impacts. have fluctuated, even as the proportion of population using solid fuels (HAP) has fallen 65. The kinetics of the changing climate also continuously since 2010. Despite this fall, air influences atmospheric dust pollution. Changes in wind patterns and strengths lead h µg/m3 = micrograms per cubic meter, that is, one-millionth of a gram. to increased PM2.5 such as, with desertifica- i Ppb = parts per billion; for ozone, 1ppb = 1.96 µg/m3 (WHO guidance at 25°C) — Microsoft Word - Conversion Factors Between ppb and.doc tion in some regions also exacerbating dust (defra.gov.uk). Climate-Related Health Risks | 33 TABLE 8. Regional and global comparisons of deaths attributable to outdoor air pollution, household air pollution, and fine partic- ulate matter in Haiti, 2016 MORTALITY RATE HAITI REGION AVERAGE WORLD AVERAGE Mortality rate attributed to household 184.3 48.33 92.43 and ambient air pollution, age-stan- Haiti is the highest in Haiti is ranked 23rd in the dardized (per 100,000 population) the region. world. Source: USAID.220 quality in Haiti is considered to be “moderately morbidity, such as the exacerbations of COPDs unsafe,” according to the 2021 WHO’s air and asthma attacks. quality guidelines.130 67. Air pollution affects pregnant women, the MENTAL HEALTH AND WELL-BEING developing fetus, or both, in ways analogous 69. The association between climate change-re- to tobacco smoking — a well-known risk lated events and mental health can be direct factor for low birth weight and preterm birth. or indirect, short-term and long-term. Acute Babies —born too small or too early — are more events (such as floods) in the short term can susceptible to health problems such as lower precipitate a psychopathological pattern similar respiratory infections, diarrheal diseases, brain damage and inflammation, blood disorders, to experiencing traumatic stress, whereas and jaundice. Low birth weight and preterm exposure to extreme or prolonged weather-re- birth are the leading risk factors for death lated impacts may result in delayed mental in the first month of life. Other vulnerable impacts, such as symptoms of post-traumatic groups are children under 5 years old and stress in the future, or psychological impacts the elderly, due to damage and inflammation on younger generations. For example, mental in the respiratory and cardiovascular systems health impacts in children can be manifested as in particular. behavioral disorders. Nonetheless, the impacts of climate change and extreme climate events 68. Improvements to air quality will result in on mental health and well-being are mediated co-benefits for the climate and the health by individual and community resilience. of populations. While those who have been exposed to air pollutants over long periods The 2019 mental disorders epidemiology may already have chronic damage to lungs for Haiti records 1,660 DALYs per 100,000 and arteries that may have evolved into population. 131 However, given that the cancers, heart disease, strokes, dementia, diagnostic capacity in the country is minimal, and COPDs in the years ahead, reducing or the data may not reflect the actuality. To be stopping exposure can halt further deteri- fair, research on the effects of mental health oration and resulting early mortality. At the outcomes related to climate change lags same time, the improvement of air quality behind the research related to physical health can also reduce triggers for acute-on-chronic at the global level. 34 | Climate and Health Vulnerability Assessment: Haiti 70. To assess mental health in the context of of the global disease burden is attributed to climate change, the full spectrum from mental health illnesses.135 Moreover, research mental “illness” to psychological and social shows that psychopathologies attributed to well-being, or “psychosocial health,” is extreme weather events have increased by considered. This allows for the incorpora- 17 percent, impacting about 30–40 percent tion of the considerations of well-being and of the population affected by the disaster. resilience.132 Adopting such an approach is Research suggests that the impacts can persist particularly relevant in Haiti, where there is up to two years after the event.136 background strain on the resilience of the population, as well as limited opportunities for 73. It is challenging to project mental health psychological or psychiatric assessments and outcomes related to climate change. In Haiti, diagnoses to inform an analysis. The concept there is a need for improved surveillance of mental health and well-being can thus be and diagnostics, as well as specialist training framed as a spectrum of “psychosocial health.” and services, to meet the mental health and It embodies the diverse psychological and well-being needs of the population. Research social strains of climate change impacts such in other countries137 have projected levels as housing, water, and income insecurities, of heat-related excess mortality for mental as well as living in physically uncomfortable disorders. These estimates may not be trans- drought or humid conditions. ferable directly to the context of Haiti; however, the trends between increasing temperatures 71. Extreme weather events can result in direct and associated mental disorders have also trauma, anxiety, and depression through been found with regard to self-harm and suicide personal injury, the death and injury of a rates. Moreover, other findings suggest that close relative, damage or loss of property, suicide rates increase by 0.7 percent and 3.1 as well as disruptions to livelihoods. Intense percent, respectively, for a 1°C increase in the negative emotions, such as terror, anger, and average monthly temperature.138 shock, are recognized acute responses to natural disasters. These extreme events 74. There are many factors that influence mental can also result in long-lasting psychological health and well-being, and the nature of distress.133,134 resilience is not fully understood. For example, there is opportunity for post-traumatic growth 72. Mental disorders, such as depression, anxiety, (PTG) following a climate change-related and post-traumatic stress, are related to extreme weather event, as opposed to the the increasing frequency of climate events. inevitability of the trauma. PTG is defined by Extreme weather events, such as floods, Tedeschi and Calhoun (1995) as “significant droughts, and storms, are becoming increas- beneficial changes in cognitive and emotional ingly common in Haiti. They are projected to life beyond levels of adaptation, psychological increase the rates of mental disorders. Although functioning, or life awareness that occur in there is a lack of information on the incidence the aftermath of psychological traumas that and prevalence of mental health disorders challenge previously existing assumptions in Haiti, global figures show that 14 percent about self, others, and the future.”139 Climate-Related Health Risks | 35 TABLE 9. Summary of the Climate Change Risks on Health Outcomes HEALTH OUTCOME RISK SUMMARY Nutrition and • Haiti is among the most food-insecure countries in the world. Food Security • Malnutrition is consistently the highest contributor to total DALYS over the 2009–2019 period, across all ages. • More than half of the population is food insecure, with more than one-fifth of the children chronically malnourished. • In the absence of adaptation, climate change is predicted to increase the duration of droughts and the frequency of flooding, resulting in reductions in crop yield,219 thereby aggravating food insecurity and increasing malnutrition. Vector-borne • In Haiti, the vectors for malaria may increase their spatial and temporal distribution, Diseases though currently, the highest rates are in the Grand’Anse and West departments. • There are also cases of dengue, chikungunya, and Zika. • All these diseases could spread, as changes in precipitation levels and internal set- tlements provide increased habitats for breeding and opportunities for the respective mosquito species to flourish. Waterborne • Waterborne and water-related diseases occur throughout Haiti due to inadequate water and Water- and sanitation systems, intense precipitation, drought conditions, and specific water related contaminants. Diseases • Contaminated water, such as through the flooding of sewage and agricultural runoffs, results in the transmission of diseases, such as dysentery, hepatitis A, and typhoid, with poor sanitation systems contributing to large and rapid disease outbreaks. • Droughts of longer duration have been linked to the reduced availability of fresh water, the deterioration in water quality, stagnation, and disease outbreaks. • Coastal communities can be impacted through saline intrusions, as sea levels rise due to climate impacts, thus affecting the local groundwater, while the increases in the surface water temperatures on the coast and in inland waterways lead to the proliferation of the toxin-producing algal blooms. • Climate change patterns will influence and expand the ecosystem opportunities, growth and transmission rates, as well as the persistence and virulence, of pathogens. Heat-related • Haiti’s under-five-year-olds are at most risk of the predicted increases in the number of Morbidity and tropical nights. Mortality • At rates of 3.1 deaths per 100,000 and 108.11 per 100,000 DALYs, increasing tempera- tures present the highest risk for under-five-year-olds in the LAC region. 36 | Climate and Health Vulnerability Assessment: Haiti HEALTH OUTCOME RISK SUMMARY Air Quality and • The disease burden, due to poor air quality, is the second-highest contributor to DALYS Respiratory across all ages. Health • Factors include particulate matter, ozone, and chemical pollutants collecting in smog-heat islands in urban and low-lying areas. • Wildfire smoke, dust, pesticides, and industrial chemicals can lead to adverse health impacts, reflecting changes in drought and wind patterns. • Exposure to air pollution, both ambient and household, increases the risks of contracting diseases such as lung cancer, stroke, heart disease, and chronic bronchitis. • Improving air quality is a priority in Haiti for the population to enjoy the co-benefits for climate and health. Mental Health • Increases in the occurrences of extreme weather events, such as floods, droughts, and and Well-being storms, also increase the incidence of mental health and well-being concerns. • The recognition of this burden across age groups in Haiti is well-documented, following significant events, such as Hurricane Matthew, in 2016. • There is evidence to support that individual and community resilience can be strength- ened to support mental health and well-being, and even PTG. Climate-Related Health Risks | 37 SECTION IV. ADAPTIVE CAPACITY HEALTH SYSTEM OVERVIEW 75. Haiti’s health system is characterized by a mix of public, private nonprofit, mixed, and private for-profit entities.140 The publicly funded health system in Haiti has three levels: the national level is overseen by MSPP, with the health depart- ment level overseen by the health department directorate, while the district and community levels are managed by the district health unit and family health team.141 Following the earthquake in 2010, Haiti developed a Strategic Development Plan of Haiti (PSDH) to guide the implementation of strategies toward recovery and development, including in the health sector.142 76. Haiti is exposed to climate hazards that However, climate change, in combination impact the health system. The health system with COVID-19, has the potential to disrupt has managed extreme climate-related events, and overwhelm health systems, including such as the 2016 Hurricane Matthew, as well healthcare facilities and healthcare staff. This as other severe natural hazards such as the is especially important in settings that may 2010 earthquake.143 Those climate and natural already have weak health systems, including disasters impacted health infrastructures, as leadership challenges, a lack of resources, well as electricity, clean water, and sanitation and / or limited capacity. systems.144 The healthcare infrastructure has been severely compromised by earthquakes, 78. The extent to which Haiti is prepared for, and has the capacity to respond to, climate-related hurricanes, and a lack of public expenditure changes is a key modifier of climate-related in the health system.145 health risks. In this assessment, Haiti’s adaptive capacityj to prevent and manage climate-re- 77. The emergence of the Coronavirus 2019 lated health risks is examined according to (COVID-19) pandemic has brought with it WHO’s six health system building blocks a focus on health systems, specifically the (Figure 15).147 These building blocks are acquisition of sufficient vaccinations for further elaborated upon in the remainder of the population, as only 0.95 percent of the this section. population is fully vaccinated. Nonetheless, Haiti has not suffered significantly during the j Adaptive capacity is defined by IPCC as “the ability of a system to adjust to climate change (including climate variability and extremes) to pandemic, specifically in relation to COVID-19 moderate potential damages, to take advantage of opportunities, or to deaths (827) and cases (30,473), since the cope with the consequences.” The related term, resilience, is the ability to prepare and plan for, absorb, recover from, and more successfully start of the pandemic, as compared to other adapt to, adverse events. People and communities with strong adaptive capacity have greater resilience. This assessment makes use of the developing countries.146 terms, “adaptation” and “adaptive capacity,” to encompass both terms. 39 LEADERSHIP AND GOVERNANCE has demonstrated its political commitment and action to address climate change challenges 79. Haiti is committed to meeting the climate through several global and country-level challenge through both adaptation and agreements and protocols — some relevant to mitigation measures — coordinated health. Table 10 highlights the key policies and and implemented by the Direction des action plans in Haiti, which include consider- Changements Climatiques (DCC) at MDE. ations of climate change challenges, starting Over the past decade, the government of Haiti from 2012. FIGURE 15. WHO’s health system building blocks Leadership & Governance Health Workforce Financing Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential Medical Products & Technologies Source: World Health Organization, 2015, Operational Framework for Building Climate Resilient Health Systems. TABLE 10. Key policies and action plans in Haiti that consider climate change challenges 2012 National Health Policy, MSPP148 The National Health Policy outlines the options adopted by the Haitian state to improve the health situation of the population and adapt it to the development requirements of the country. The policy highlights the suitability of the tropical climate for the development of vectors, particularly the An. and Ae. vectors of malaria and dengue fever. There are no other considerations for climate-health risks. 2012 Strategic Program for Climate Resilience (SPCR), Inter-ministerial for Spatial Planning and Inter-Ministerial Committee for Land Planning149 Haiti developed the SPCR under the Pilot Program for Climate Resilience to mainstream climate change into national development planning.150 The objective of the SPCR is to reduce the country’s vulnerability to climate change in target regions experiencing different levels of risks. It also forecasts the conse- quences and impacts of climate change on key sectors of the national economy, as well as strengthens the resilience of both rural and urban communities in the target regions. It includes projects on climate change adaptation in the coastal cities of the Golfe de La Gonâve and strengthens the knowledge man- agement of climate data to inform decision-making and policy dialogues. This program was supported by development partners including the World Bank Group, the International Development Bank, the African Development Bank, and the European Bank. 40 | Climate and Health Vulnerability Assessment: Haiti 2013 Second communications on climate change, Direction des Changements Climatiques (DCC), MDE151 The national communication is the result of a series of activities carried out under the auspices of DCC — the national political authority for policies and the implementation of actions in this area. The second national communication on climate change provides relevant information on the evolution of GHGs, mitigation measures, the country’s vulnerability to extreme climatic events, and adaptation options. This includes the promotion of building techniques that limit CO2 emissions and other pollutants in order to improve indoor and outdoor air quality. As such, it guides decision-making, in terms of mitigation and adaptation to climate change. 2014 Haiti Sustainable Energy Roadmap, Ministère des Travaux Publics, Transports et Communications152 The Haiti Sustainable Energy Roadmap looks at options for integrating renewable resources as much as possible into the energy sector of the country, focusing on those that are most appropriate. The recommended options for Haiti include hydropower, solar energy, wind resources, biomass, and biofuels. Additional recommendations, related to air pollution, identify the need for Haiti-specific data on the environmental and health impacts of power plants, including local pollutants and GHGs, as well as supplying efficient cookstoves and alternatives to charcoal to reduce HAP. This roadmap was developed in collaboration with the Worldwatch Institute. 2015 Intended Nationally Determined Contribution, MDE153 The Intended Nationally Determined Contribution (INDC) of the Republic of Haiti provides relevant information on the proposed effort to address climate hazards. The INDC outlines guidelines, on which the government’s actions will be based for the next 15 years, for adapting to climate and reducing GHG emissions by 31 percent. The INDC highlights the country’s adaptation priorities as the integration of water resources, watersheds, and coastal zone management; the rehabilitation of infrastructure; the improvement of food security; along with information, education, and awareness. 2006 National Adaptation Plan of Action (NAPA), MDE154 (Revised in 2017) The NAPA is an important multisectoral and multidimensional exercise for implementing the National Policy on Climate Change. It is a driving force to accelerate Sustainable Development Goals (SDGs) by putting in place economic and investment scenarios. The priorities highlighted include watershed management and soil conversion, coastal zone management, the valorization and conservation of natural resources, the improvement of food security, water protection and conservation, the construc- tion of rehabilitation of infrastructure, waste management and information, as well as education and awareness, with the first three considered to be top priorities. In terms of climate-health risks, the NAPA has identified drought-related hypertension. There are some adaptation projects155 aligned to the NAPA, including the following: • Building Adaptive Capacity of Coastal Communities in Haiti (2011–2016).156 The project aims to promote development that protects the local communities from climate change impacts. This includes creating resilient economies and societies, while reducing risks for vulnerable populations in Haiti. • AP3C Project (2015–2020). It aims to reduce Haiti’s vulnerability to climate change through improved coordination on adaptation and mitigation and the improvement of the national environ- mental legislation — funded by the European Union’s (EU) Global Climate Change Alliance (GCCA). • Pilot Program for Climate Resilience (2014–2021)157 funded by the Inter-American Development Bank and the World Bank. This is a Caribbean regional program for building resilience in six countries (comprising Dominica, Grenada, Jamaica, St Lucia, and St Vincent and Grenadines). Objectives are integrated, with a focus on building capacity for climate resilience in development policies and planning, as well as scaling up and mobilizing climate resilience. Adaptive Capacity | 41 • Ecosystem-based adaptation (2016–2020) funded by the Global Environmental Facility. The objective of the project is to increase the resilience of ecosystems and vulnerable communities through biodiversity conservation and the watershed management of three rivers in the country.158 • Capacity-building project to implement Multilateral Environmental Agreements (2016–2018), supported by the UN environment program.159 2019 National Policy to fight Climate Change, MDE160 The National Policy on Climate Change aims to build on institutional strengthening and improvements in governance, endogenous climate financing, and efficiency in actions for fighting against climate change. 2019 National Disaster Risk Management Plan161 The National Disaster Risk Management Plan includes strategies to increase preparedness for disasters to ensure an effective response and quick recovery. The policy document describes climate change as a major risk on current and future strategic sectors for the country’s economy. However, climate-health risks and consequently, adaptation strategies, are not addressed. 2021 Health Master Plan 2021–2031162 The Health Master Plan sets out the path that Haiti intends to follow toward universal health coverage (UHC). The plan is based on WHO’s six building blocks (leadership & governance; financing; health workers; essential medical products & technologies; health information systems [HIS]; and health services). The document acknowledges that air quality is threatened, and that vulnerability to natural disasters, particularly floods, has increased considerably due to deforestation and impacts to water- sheds. However, the report does not offer planning on climate health-risks and adaptation strategies. 2022 National Adaptation Plan (NAP) 2022–2030 The NAP provides adaptation actions for four key priority areas: agriculture, health, infrastructure, and water resources. These areas are prioritized due to their socioeconomic relevance and vulnerability to climate change. For the health sector’s priority area, the adaptation actions focus on health insurance; the development of a climate-resilient health infrastructure; capacity building to ensure “first aid” for all Haitians; maternal care; the support of vulnerable populations; the promotion of natural medicine; along with the strength- ening of health policies accounting for climate-related hazards and their awareness. The NAP includes cost estimates for implementing the proposed actions. Health-specific cost lines for health prevention and WaSH are projected to be slightly below USD13.5 million — less than 1.5 percent163 of the total estimated budget. HEALTH WORKFORCE irregular salary payments, as well as a lack of medical supplies and essential resources; 80. Haiti has challenges in building and retaining and poor retention164 characterized by inter- a strong health workforce, particularly in national migration. the public sector. Haiti is one of the 57 countries defined as having a crisis in human 81. Attracting and retaining qualified health resources for health (HRH). For example, there professionals is a chronic challenge, with are concerns about the quality of education, as few as six health professionals per 10,000 standards, and accreditation; poor career people.165 In 2018, Haiti was reported to have structures and skill mix in the workforce; an estimated 2.3 medical doctors and 3.97 urban-rural maldistribution, with specific nurses and midwives per 10,000 population, issues with rural retention; insufficient and which is below WHO’s minimum threshold for 42 | Climate and Health Vulnerability Assessment: Haiti UHC — 44.5 per 10,000.166 In total, there were to climate-health risks, such as heat exposure an estimated 2,606 registered doctors, 4,227 and vector-borne and waterborne diseases, nurses, and around 197 midwives.167 Moreover, along with the management of mental health there is a shortage of other health profes- conditions. sionals: for example, there were 1,731 medical pathologists and laboratory technicians, and 84. Salary payment systems for health workers by 2016, around 0.077 psychiatrists worked have curtailed health workforce capacity. in the mental health sector per 100,000.168 Until 2018, health workers were paid by direct According to WHO, there are no environ- deposit. Widespread corruption resulted in mental health workers in the country. The the MSPP making salary payments by checks. shortage is worsened by the outmigration However, such a process requires health of medical doctors and nurses due to a lack workers to travel to urban centers to pick of adequate labor conditions.169 up their salary payments, thus leading to the loss of a workday and disincentivizing health 82. The training and recruitment pipeline faces workers to work in rural areas.175 Moreover, challenges. On average, 352 medical doctors, delays in salary payments and insufficient 4,234 nurses, and 75 midwives graduate from remuneration are a common trend among Haiti’s educational institutions each year. With health workers, constituting a primary cause bilateral cooperation agreements supporting of international outmigration.176 the training of medical doctors for Haiti, the total number of medical doctors reaches 85. NGOs are an essential part of the healthcare approximately 500–600.170 However, after workforce. Organizations such as Partners in their studies, about 24 percent of medical Health (PIH) have been working to improve doctors, 87 percent of nurses, and 59 percent healthcare access in Haiti since the early of midwives remain unemployed due to insuf- 1980s. The organization employs around 6,300 ficient recruitment resources.171 health staff, including 2,500 community health workers. They attend to more than 1.3 million 83. The health workforce, particularly doctors people in primary care, maternal and child and nurses, is more concentrated in urban health care, HIV, tuberculosis, mental health, areas. Eighty percent of medical staff are and more advanced care. A part of their work located in urban health facilities, leaving less is focused on providing training to the health than 20 percent in rural areas where half of workforce; they offer six residency programs. the population lives.172,173 Both the private and Although PIH’s workforce has provided government health sectors face shortages of services during extreme weather events doctors, nurses, and community health workers such as hurricanes, there is no information in rural areas. Traditional medicine and healers regarding the integration of climate change are typically linked to local religions and widely impacts on health as part of the training of used in areas lacking in licensed practitioners; their health staff.177 for example, traditional birth attendants are responsible for around 75 percent of birth 86. International aid and short-term medical deliveries in the country.174 However, there missions (STMMs) are common in Haiti; is no data on how these traditional practices they help to mitigate the health workforce and practitioners manage conditions related shortage. However, these platforms tend to Adaptive Capacity | 43 result in unregulated activities, which are not primary goals, it seeks to strengthen the integrated into the national health strategic health workforce and the health system. planning. There is a need to coordinate STMMs Moreover, it aims to improve labor conditions with local health officials, so that there can and retention mechanisms to improve health be appropriate coordination, regulation, and workforce deployment in the country. However, distribution of an accredited health workforce there is no mention of climate change in this to areas of the greatest need. Moreover, it document or training to manage specific is pivotal to incorporate the STMMs into a climate-related health risks. Both professional climate-health adaptation national strategy.178 training (for example, medical and nursing schools) and continued professional training 87. Efforts with multilateral stakeholders, such (for example, on-the-job, post-graduate, and as the United States Agency for International in-service training) mechanisms lack compre- Development (USAID) and the Health Finance hensive information on understanding and and Governance Project (HFG), have focused reducing the health risks of climate change on evaluating and improving conditions for or training on disaster response, such as for human resources among public and private floods, mudslides, and extreme events. health institutions. For example, HFG has developed guidelines and programs to 89. The extent to which Haiti’s health workforce improve the accreditation process of medical has adequate knowledge, technical capacity, doctors, nurses, and community health workers and resources to prevent and manage current through the Reconnaissance project.179 Efforts and future climate-change-related health to improve access to quality health services risks remains unknown. There is a lack of a have prioritized the health workforce, yielding health workforce, and even with an adequate the first Plan Stratégique de Développement workforce, there are not sufficient resources. des Ressources Humaines pour la Santé.180 Although some training materials have been Furthermore, HFG and USAID have worked developed for extreme weather events such alongside the Directorate of Human Resources as hurricanes, expansion is needed across within MSPP to evaluate the capacity and climate-sensitive disease programs, including conditions of human resources in public and the development and adaptation of educational private health institutions.181 These initiatives, curricula and training materials, as well as the supported by improvements in health financing integration of climate change into in-service management, seek to ameliorate workforce health worker and community health worker conditions and the retention of the human training programs. capital in the country.182 88. There are no capacity-building programs in HEALTH INFORMATION AND DISEASE place that address the context of a changing climate and the capabilities of the health SURVEILLANCE SYSTEMS workforce to prepare for, prevent, as well as 90. Historically, there have been issues with respond and adapt to climate change-related incomplete data, inaccurate data, the health risks. Haiti developed a Strategic Plan lack of timely data collection, and parallel for the Development of Human Resources information systems among various partners in the Health Sector for 2030. Among its working in health. In addition, the information 44 | Climate and Health Vulnerability Assessment: Haiti that is available is not always analyzed and Following the 2010 earthquake, key programs used for decision-making in health planning and services were appraised as part of the and policy.183 One of the main challenges is post-earthquake response and recovery to set up and implement an effective and planning, which has taken a central role in efficient structure that is capable of reorga- informing current and future strengthening nizing and consolidating the various HIS, in and prioritization within the health sector.186 order to effectively support evidence-based The disease surveillance system has been decision-making at all levels: institutional, local, expanded and strengthened, facilitated district, and central. by both disease surveillance, as well as outbreak management and clinical services.187 91. Since June 2008, the Pan American Health Nonetheless, there is still a lack of climate-in- Organization (PAHO) / WHO has been formed programs, such as early-warning supporting MSPP to create a National Health monitoring systems. Furthermore, there is Information System that will consolidate all also a need to establish and strengthen relevant health information for use in health current initiatives monitoring and addressing planning, decision-making, and action. This nutritional risks that are being exacerbated by system will include information on morbidity, climate change, as food security has been a mortality, health systems, health services, historical healthcare challenge in Haiti. human resources, and health financing at all levels of Haiti’s healthcare system. Unfortu- nately, there was a considerable setback for ESSENTIAL MEDICAL PRODUCTS the health information system project, when the 2010 earthquake destroyed the MSPP AND TECHNOLOGIES building, where the Planning and Evaluation 93. In 2016, the Haiti government endorsed the Unit was located. Information on the recent essential service package (PES): it included progress of the development of the system a requirement for a range of basic health is limited. services; a list of drugs and equipment; and a minimum number of staff required 92. There are climate-related and natural for each level of care.188 The Global Fund disasters information technologies relevant to provides health facilities with the resources health and health systems being developed to manage cases of malaria, HIV/AIDS, and in Haiti. Disaster risk management (DRM) tuberculosis free of charge, and other supplies includes evaluating, adapting, and improving are purchased from MSPP’s storage and early warning systems and disseminating the registered distributors, where possible. information.184 Initiatives — such as Haiti Data that produces data regarding climate-related While the PES specifies the standards of imple- events like floods, cyclones, earthquakes, mentation, it does not address how they are water scarcity, and landslides — are pivotal delivered. In actuality, implementation has for developing climate-related health risk stagnated due to the lack of basic infrastruc- estimation models. They show excellent ture, resources, and skills. The healthcare potential for improving resilience in the system — from preventive to critical care — healthcare system.185 is inadequately equipped. Stockouts are Adaptive Capacity | 45 common in health facilities in Haiti. Another 96. Health infrastructure, including healthcare example is the powering of the solar-pow- facilities, especially in remote areas, is also ered refrigerator for cold chain requirements, vulnerable to extreme weather events, which are available at most rural health centers becoming inoperable during events when and dispensaries; however, they rarely have they are most needed. The government’s a functioning power system to ensure a preventive and curative services in Haiti are constant electricity supply. These gaps and delivered through dispensaries, health centers vulnerabilities in equipment and supplies have without beds, health centers with beds, and exacerbated the impact of climate-related hospitals equipped with intensive care units health risks. There is no recent information (ICUs) (Table 11). Private healthcare facilities available on the implementation of the PES. constitute almost half of the services (46.76 percent), followed by public facilities (37.21 percent) and facilities that are a mix between HEALTH SERVICE DELIVERY public and private services (16.03 percent).194 94. Healthcare delivery in Haiti remains fragile, 97. A lack of transportation and adequate roads characterized by the limited coverage of in rural areas makes access to health facilities primary care services and suboptimal a challenge for around half of the total healthcare performance, resulting in consid- population. Not all communes195 have all levels erable health vulnerability for the Haitian of health facilities, with research suggesting population.189 Approximately 40 percent of that distance accounts for why 37 percent Haiti’s population lacks access to essential of the population does not seek healthcare health and nutrition services.190 Geographic attention.196 Moreover, remote villages are access to the health service is limited for the accessible only by foot, and roads connecting rural population, in particular. This limitation is villages with towns are often unpaved and attributed principally to the insufficient number inaccessible when riverine flooding occurs. of facilities, the difficulties in reaching the There is a lack of reliable and affordable facilities, and local customs.191 Poor facilities public transportation, and national ambulance and service delivery in Haiti also diminish services are only available in certain zones.197 service utilization. As a result, primary care of good quality is accessible to only 23 percent 98. A lack of healthcare system capacity of the population: 46 percent in urban areas exacerbates risks from climate change. and 5 percent in rural areas.192 Recent research shows the lack of resilience in critical care healthcare infrastructure in Haiti 95. Extreme weather events, such as hurricanes (see Table 2), with most of its infrastructure and tropical storms, have strained the concentrated in urban areas. The country lacks healthcare system. The increased intensity of sufficient facilities with adequate numbers these events has limited access to medication, of ICU beds. Only 17.4 percent of the critical medical advice, supply and cold chains, care facilities are equipped with ICU beds. and clinic visits with appropriate healthcare Consequently, 80 percent of critically ill patients personnel, thereby hampering the management in hospitals without ICU are taken care of of diseases and conditions.193 in the emergency department, which is also inadequately equipped.198 46 | Climate and Health Vulnerability Assessment: Haiti TABLE 11. Number of healthcare facilities, by type, across provinces DEPT. CATEGORY STATUS DEPARTMENT DISPENSARIES HEALTH CENTERS HEALTH HOSPITALS PUBLIC PRIVATE MIX (%) (%) WITHOUT BEDS CENTERS WITH (%) (%) (%) (%) BEDS (%) Artibonite 21.43 5.51 10.88 8.20 17.44 12.24 5.95 Centre 7.83 4.06 8.16 3.28 6.67 4.90 8.33 Grand’Anse 8.29 2.61 3.40 2.46 6.92 1.63 10.71 Nippes 4.61 0.58 4.76 2.46 2.56 0.82 10.71 Nord 8.76 12.75 7.48 10.66 7.44 12.45 9.52 Nord-Est 5.53 2.32 5.44 1.64 7.44 1.22 4.17 Nord-Ouest 15.90 2.32 8.16 3.28 14.62 4.69 7.74 Ouest 12.44 59.71 36.05 57.38 20.00 52.45 28.57 Sud 8.76 4.35 9.52 8.20 8.46 4.69 12.50 Sud-Est 6.45 5.80 6.12 2.46 8.46 4.90 1.79 Total 100.00 100.00 100.00 100.00 100.00 100.00 100.00 DISPENSARIES HEALTH CENTERS HEALTH HOSPITALS (NO.) WITHOUT BEDS CENTERS WITH (NO.) (NO.) BEDS (NO.) Total 434 345 147 122 Source: Liste des Institutions Sanitaires Du Pays (MSPP 2015). 99. Longer-term strategies on DRM, such as 100. Essential infrastructure, including projecting climate change trends, have health-related infrastructure, must be planned been identified as part of a comprehensive after assessing the information relevant to an approach for some climate-related health area’s geographical distribution, vulnerability, risks, with the aim of reducing the future and hazard occurrence in order to reduce the burden. The disaster risk management report risk of damage from climate-related events.201 2019–2030199 includes climate change as a Healthcare infrastructure design needs to critical variable for the country’s strategic incorporate climate-smart features in order planning on disaster risk reduction and to reduce building damages or losses during management. It highlights the need to build extreme climate-related events. Protection cooperation between different governmental from flooding events or hurricanes requires institutions, private initiatives, and community that existing infrastructure be guided by overall organizations. It also highlights the need for strategies for the management of water, strong decentralizing health and social services winds, and floods, as well as future climate to increase access to health and essential projections. Moreover, earthquake prepared- services across the national territory.200 ness can also enhance climate adaptation, as there is an important crossover for strength- ening health service delivery and the overall health system capacity. Adaptive Capacity | 47 The extent to which infrastructure assessments increase in OOP expenditure to USD43.583 for the health sector are being conducted, (as a percentage of total health expendi- building designs are incorporating projected ture).207 It is estimated that approximately climate change impacts, and retrofitting 90 percent of the health operating budget measures are being carried out are still unclear. goes to the payment of workforce salaries.208 There has been no comprehensive review of The health expenditure budget is made on the healthcare infrastructure to identify climate a year-to-year basis, making it difficult to change-related vulnerabilities and opportuni- plan and address structural needs in the ties to improve its climate resilience. healthcare sector.209 103. Risk pooling in Haiti does not account for FINANCING climate and health-related risks. The Office 101. The budget of the government of Haiti for d’Assurance Accident du Travail, Maladie et health is limited. Despite its recent contri- Maternité (OFATMA) is a public institution bution for the purchase of routine vaccines, offering health insurance and social protection the country relies heavily on international to employees in the public and private funding and out-of-pocket (OOP) expendi- sectors.210 OFATMA is mandatory for formal tures for Haitians to have access to health private and public sector employees, and services.202 The healthcare sector has been voluntary for those working in the informal severely compromised due to both climate sector.211 The Office National d’Assurance and natural disasters such as earthquakes and Vieillesse (ONA) offers insurance to the elderly hurricanes, and a lack of public expenditure and disabled.212 Private and public companies in the health system. Public health spending provide health coverage through OFATMA for decreased from 16.6 percent in 2004 to 4.4 their employees and dependents; however, percent as of 2017.203 The 2018–2019 budget these benefits constitute small, fragmented allocation for the health sector showed risk pools within each company.213 a further decline from 4.8 percent to 3.9 percent.204 In general terms, illnesses and health care costs are not evenly distributed, with some 102. Although 57 percent of the health budget population groups facing higher health went to curative care and 33 percent went risks, which may be exacerbated by climate to preventive care205 during the 2013–2014 change. Climate change can exacerbate period, there were no clear considerations underlying health burdens, while increasing of climate-related preventive investments. the potential and size of certain catastrophic During the same period, the health budget of financial health risks, especially among the USD59.5 billion comprised (a) donor funds most vulnerable. (56.7 percent), (b) OOP expenditure (30.1 percent), (c) the government’s domestic 104. Haiti’s reliance and dependence on donors / budget (9.7 percent ), and (d) the private aid for health expenditure makes it sector (3.5 percent). By 2018, Haiti expended vulnerable, in terms of its ability to ensure 7.695 percent of its total gross domestic the financing sustainability of climate-health product (GDP) on health206 (USD64.246 programs. For example, donor funding went expenditure per capita) and registered an from USD44 per capita in 2011 to USD15 in 48 | Climate and Health Vulnerability Assessment: Haiti 2016. International financing and aid tend Building resilient health systems for climate to be detached from a national plan. There change requires budget allocation as an is no systemic approach in consolidating integrated component in the overall planning information on contributions and programs of a national health plan. Although Haiti from foreign aid and NGOs. has prioritized climate change projects — mostly on water conservation and DRM, 105. From 2011 to 2014, the country received a these efforts have not focused on the health total of USD282 million for climate-disaster sector. Ultimately, guidelines for integrating relief, being the number-one country of a climate-resilient approach for health care 35 small island developing states (SIDS). and public health systems are not available Currently, there is a total of USD1.3 billion to inform rationalized resource allocations. of international funds channeled to climate change or climate-related projects.214 Of the 107. A total of 76 climate change-related USD1.1 billion for long-term projects, USD773 projects217 have been developed in Haiti; million are focused on sustainable energy. however, none of them prioritize the health Among most of the projects currently funded, sector. Although some climate change 50 percent comprise adaptation projects, projects indirectly impact human health issues 21 percent mitigation, and 29 percent both due to climate change, such as food security mitigation and adaptation.215 These funds are efforts, or water and waste management, being distributed among four main areas: (a) international funding is not being used to food security; (b) disaster risk reduction; (c) conduct health-based adaptation measures. renewables and energy; and (d) integrated water system management.216 108. The health co-benefits of climate change mitigation have not been adequately 106. There is no evident allocation of funding by promoted as cost-effective options. the government of Haiti that is dedicated Arguments for implementing climate change to addressing the impact of climate change mitigation policies often focus on perceived on health and health systems. Although short-term financial costs. However, cost there is a commitment in the government’s assessments rarely account for the health National Adaptation Plan to Climate Change co-benefits of these policies — strengthening and their National Plan on Disaster Risk the resilience and outcomes for human health. Management, there is no precise strategic Therefore, additional studies are needed to planning for climate-health finance and quantify the longer-term cost savings from resource allocations for climate-related adopting the health co-benefits of climate health risks and vulnerabilities. The lack change adaptation policies in Haiti. of a long-term vision increases the risk of the sustainability of climate-related health projects. Adaptive Capacity | 49 TABLE 12. Summary of the health system adaptive capacity gaps for Haiti BUILDING BLOCK SUMMARY OF GAPS IN ADAPTIVE CAPACITY Leadership and • Haiti is committed to meeting the climate challenge through both adaptation and Governance mitigation measures; however, the coordination mechanism to facilitate cross-sec- tor action on climate change and health is limited. • Consideration for climate-health related risks is limited in national health policy documents. Health Workforce • The number of skilled health professionals is well below WHO’s minimum threshold for achieving UHC, with notable urban-rural discrepancies. • There are existing HRH capacity issues pertaining to the lack of proper skill-mix; the inadequate quality of education, standards, and accreditation; the health system’s poor absorption capacity; the outmigration of medical doctors; and career structure challenges. • There is a lack of a systematic approach for capacity development on climate-re- lated health risks, while emergency preparedness and responses constitute a key challenge for Haiti’s health workforce. Health Information and • There are incomplete data, inaccurate data, a lack of timely data collection, and Disease Surveillance parallel health information systems. Systems • There is a lack of climate-informed programs, such as early warning and monitor- ing systems. • There is no recent comprehensive review of HIS in Haiti. Essential Medical • There are important gaps between policies and practice for essential medical Products and products and technologies, including infrastructure and resources. Though there Technologies are standards for essential medical products, how they should be delivered is not addressed. • The country lacks sufficient facilities with enough ICU beds. Health Service • Health service delivery is challenging in Haiti, stemming from fragmentation, Delivery limited national institutional capacities and technical expertise, and the develop- ment of parallel vertical programs at the federal and provincial levels. • Coordination across sectors to ensure that climate risks are being incorporated into infrastructure planning is inadequate. • There is a lack of access to healthcare facilities in rural areas. Health Financing • There are no budget estimations for long-term strategic planning. • Haiti’s reliance and dependence on donors / aid for health expenditure make it vulnerable, in terms of sustainable financing for its climate-health programs. • There is no evident allocation of funding dedicated to addressing the climate change’s impact on health and health systems within the health sector. 50 | Climate and Health Vulnerability Assessment: Haiti SECTION V. RECOMMENDATIONS TO ENHANCE HEALTH SYSTEM RESILIENCE TO CLIMATE CHANGE 109. This section describes recommendations for enhancing Haiti’s health system resilience to climate change, including health interventions and strategies for adaptation. Organized according to WHO’s operational framework for resilient health systems (Figure 16) and drawing from consultations and review of all relevant governmental policies, as well as the World Bank’s Health, Nutrition and Popu- lation (HNP) Climate and Health Guidance Note, the recommended options are based on an assessment of both the magnitude of the current and projected cli- mate-related health risks, along with the existing gaps in the country’s adaptive capacity to manage and / or prevent these risks. FIGURE 16. WHO’s Operational framework for building climate-resilient health systems ATE RESILIENCE CLIM hip & Heal ders Workf th Lea vernance orce Go V uln pac ation t Fin alth & A Ca apt men He ate era ity & Leadership As g d ess Clim cin bil & Governance Health s ity, an Workforce Financing Preparedness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential C li o r m e h Re ima & I n f a lt s Medical ma d C l a lt h se te Products & h He ra m Pro te a rc Technologies He - g Ma nt na ili e Env ge m ent o m a t e Res le f C l i ir o n in a b D et m ental & S u st a gies ri m e o lo n ts Tech n re of H ct u e a lt h I n f r a s tr u & Source: World Health Organization, 2015, Operational Framework for Building Climate Resilient Health Systems. 51 110. The CHVA recommendations are aligned (NDC) 2.0 (2022), as well as those in the with the guiding principles for the World HNAP. This monitoring mechanism should Bank’s Strategy for Fragility, Conflict and be able to track the progress of the activities Violence 2020–2025.218 These principles of the Haiti government, as well as those of focus on (a) addressing the drivers of fragility its development partners. and short- and long-term risks, including climate-related shocks; (b) protecting essential institutions, such as MSPP, and HEALTH FINANCING ensuring resilient governance; (c) strength- 113. Establish a budget line item with MSPP ening the capacity of core institutions and that is aimed at implementing adaptation their legitimacy; and (d) mitigating the measures for the health sector and providing consequences of an FCV context, which funds for preparedness for extreme weather can be exacerbated by climate and health events. challenges, by supporting the most vulnerable communities. 114. Develop a monitoring system to track funds from the MSPP and its development partners Furthermore, recommendations to strengthen that are being directed to climate and health the health system’s resiliency could also projects and programs. This system could incorporate social protection systems in be intertwined with the progress tracking order to enhance human capital and reduce system of the NAP. inequalities, contributing to reducing risks in the context of fragility and conflict in Haiti. The provision of adaptation and mitigation SERVICE DELIVERY interventions for strengthening the health 115. Develop standard operating procedures system — in response to a changing climate (SOPs) that account for climate-related — needs to bolster the government’s capacity health risks and ensure the continuity of and political legitimacy in ensuring resilient the provision of health services during systems in Haiti. extreme weather events. These SOPs could be developed at the facility level, focusing on primary healthcare services, and at the LEADERSHIP AND GOVERNANCE system level, ensuring the procurement of 111. Develop a climate and health action pharmaceutical and medical equipment in plan based on the newly released HNAP line with climate-related health risks. 2022–2030. This action plan would focus on the 85 adaptation actions in the health 116. Enhance disaster contingency planning, priority area (Encadre #2) identified in the specifically including the deployment of HNAP. medical products to aid the response to climate shocks. This would include integrating 112. Establish a mechanism to monitor the health climate-related health considerations into sector’s adaptation measures and related district- and community-level disaster indicators. This mechanism would need to management plans and will need to involve include the adaptation actions included in the coordination between MSPP and other the Haiti Nationally Determined Contributions stakeholders (such as NGOs and community 52 | Climate and Health Vulnerability Assessment: Haiti organizations) for organizing activities related HEALTH INFORMATION SYSTEMS to preparedness and emergency responses. 120. Expand the utility of Haiti Data to 117. Review national building codes to incorporate complement the hydromet information the requirements of healthcare facilities by currently available with climate-related taking into consideration exposure to acute health information. Data sets could be climate shocks and the need to maintain complemented with targeted modeling and service delivery. Importantly, this review the important analysis of outputs, through could include the incorporation of climate the publication of frequent reports and risk projections into these codes / permits. recommendations, to assist policymakers and planners in the decision-making process. 121. Develop early warning systems for HEALTH WORKFORCE extreme weather events that integrate and 118. Work with existing initiatives to incorporate disseminate information on climate-related climate considerations into national health health risks. These early warning systems worker accreditation programs. This could be linked with a centralized emergency approach could build on the continuing operations center system in order to facilitate efforts of the former “Reconnaissance” the decision-making process. It could utilize accreditation system that has now transi- mobile telephone platforms to send timely tioned to the ownership of Haitian institutions information to health and emergency profes- and expanded from its origins with nursing sionals, and the general public. staff to incorporate schools of medicine and pharmacy. 119. Design and implement measures that provide incentives and increase the retention of the healthcare workforce in rural areas. Key NGOs, such as PIH, could be a key part of these measures. Issues that could be prioritized are expected to include the payment system, which impact rural workers in particular. Recommendations to enhance health system resilience to climate change | 53 ANNEXES ANNEX A. METHODS FOR ESTIMATING presenting suitable conditions for vector breeding and suitable conditions for vector breeding where MOSQUITO SUITABILITY IN HAITI, humans are present (that is, populated areas).   UNDER RCP8.5 To demonstrate the plausible spatial distributions of the vectors of dengue and malaria, spatial models ANNEX B. ASSUMPTIONS ON were constructed to assess the risk propensity THE COURSE OF FUTURE GLOBAL of these diseases. Climate data are taken from the historical reference period (1986–2005), CLIMATE CHANGE  the 2030s, and the 2050s. The epidemiology Predicting the future climate of any country requires of VBDs is directly influenced by environmental several assumptions to be made about the direction factors that facilitate vector development and of the future global climate. The World Bank’s survival. It is important to recognize that spatial CHVAs follow the RCPs developed by IPCC. They modeling results are limited by the input data’s describe four scenarios along which the climate spatial resolutions and the parameterization of of the planet might change over the coming predictor variables, as demonstrated from the decades. The four RCPs are named according literature review including laboratory studies. to the assumed level of global radiative forcing and the difference between the energy absorbed Here, results are largely a function of minimum by planet Earth versus the energy reflected back and maximum temperatures (that is, the thermal into space by 2100. tolerance levels of vector species), as well as LULC (that is, the characteristics of the species’ The radiative forcing is measured in watts per preferred habitats), whose input data’s spatial square meter, resulting in the four IPCC RCPs as resolutions are 25 km and 100 m, respectively. follows: RCP2.6, RCP4, RCP6, and RCP8.5. Each These resolutions provide large, rather than RCP shows the planet trapping progressively higher fine-scale, estimations of suitable breeding areas. amounts of energy from RCP2.6 (the lowest) to RCP8.5 (the highest). A wide range of factors will In addition, this methodology does not incorporate determine which RCP will most closely predict sociodemographic factors, which can play an the course of the planet’s future climate for the appreciable role in facilitating or curtailing vector rest of this century.   breeding risk. To determine the population at • Mid-range emissions (RCP4.5): This scenario is risk of these VBDs, suitable areas were spatially a stabilization scenario that assumes action is overlaid with population data from the Global taken by all countries to curb climate change, Human Settlement Layers (2015) to calculate the resulting in a global average temperature rise population residing in suitable areas, by region. of no more than 2°C and 3°C above pre- Population data are held constant in all models, industrial temperature levels by 2100.  in the absence of spatial population projection information. As such, these results should be taken • High-end emissions scenario (RCP8.5): as a conservative estimate of the areas of Haiti This scenario represents the extreme end 55 of plausible climate change, delivering an The baseline period covers 30 years, since this estimated global average temperature increase has conventionally been the length of time over of about 5–6°C by 2100 (NOAA 2021), relative which climatic conditions are measured to reduce to pre-industrial temperature levels. RCP8.5 is the noise from annual or other cyclical variations. currently recognized as “business as usual.” Looking to the future, 20-year time periods are Given today’s current environment, RCP8.5 used as a consequence of the accelerating pace is the most realistic scenario for the future.   of change of global climate, which also allow for the analysis of climate-related threats over For the purposes of the World Bank’s vulnerability a sufficiently proximate timescale.     assessments and the specific near-to-mid-term time periods — 2030s to 2050s, RCP8.5 is the • 2030s: This is the 20-year period from 2020 most likely scenario, and it is the one being used to 2039, with 2030 as the chronological mid- throughout the assessment. RCP4.5 can be useful point. It can be seen to represent the immediate as a risk comparison to demonstrate a plausible coming years to which countries and their “avoided impact” through strong mitigation efforts.   governments need to respond with utmost urgency.  In addition to selecting the most likely scenario • 2050s: This is the 20-year period from 2040 to for the future global climate, it is also useful to 2059, with 2050 as the chronological mid-point. define a baseline period to represent the current It can be seen to represent a medium-term climate within which observed health impacts period, still well within the lifetime of current have occurred. It is also helpful to define future populations over which countries and govern- time periods that can be compared against this ments have sufficient time to make profound baseline, and for which assumptions or models can changes in preparation for expected threats.   be used to predict changes in future climate-related disease burdens. The World Bank’s CHVAs use two 20-year time periods: together, they cover the next four decades to show imminent climatic changes and medium-term climatic changes in a given country.   56 | Climate and Health Vulnerability Assessment: Haiti REFERENCES 1 Intergovernmental Panel on Climate Change. 2021. Sixth Assessment and Kimberly A. Stephenson, 2021, “Generating Projections for the Report. https://www.ipcc.ch/assessment-report/ar6/. Caribbean at 1.5, 2.0, and 2.5◦C from High-Resolution Ensemble,” Atmosphere 12 (3): 328, doi: 10.3390/atmos12030328. 2 Intergovernmental Panel on Climate Change. 2021. Sixth Assessment Report. https://www.ipcc.ch/assessment-report/ar6/. 22 Tannecia S. Stephenson and Jhordanne J. Jones, 2017, “Impacts of Climate Change on Extreme Events in the Coastal and Marine 3 Robert J. Nicholls and Anny Cazenave, 2010, “Sea-Level Rise and Environments of Caribbean Small Island Developing States (SIDS),” Its Impact on Coastal Zones,” Science 328 (18): 1517–20, doi: 10.1126/ Caribbean Climate Change Report Card: Science Review: 10–22. science.1185782. 23 Bhawan Singh, Marc J. Cohen. 2014. Climate Change Resilience: The 4 World Bank. Climate Change Knowledge Portal. https://climateknowl- case of Haiti. Oxam Research Reports. https://www-cdn.oxfam.org/ edgeportal.worldbank.org/. s3fs-public/file_attachments/rr-climate-change-resilience-haiti-260314- 5 The Emergency Events Database. https://public.emdat.be/. en_2.pdf. 6 The Emergency Events Database. https://public.emdat.be/. 24 Thomas R. Knutson, John L. McBride, Johnny Chan, Kerry Emanuel, Greg Holland, Chris Landsea, Isaac Held, James P. Kossin, A. K. 7 World Bank. Climate Change Knowledge Portal. Country: Haiti. https:// Srivastava, and Masato Sugi, 2010, “Tropical Cyclones and Climate climateknowledgeportal.worldbank.org/country/haiti/vulnerability. Change,” Nature Geoscience 3 (3): 157–63, doi: 10.1038/ngeo779. 8 Intergovernmental Panel on Climate Change. 2021. Sixth Assessment 25 World Bank. Climate Change Knowledge Portal. Country: Haiti. https:// Report. https://www.ipcc.ch/assessment-report/ar6/. climateknowledgeportal.worldbank.org/country/haiti/vulnerability. 9 Global Facility for Disaster Reduction and Recovery. Think Hazard. 26 Jane A. Palmer, “Slippery Slope: Could Climate Change Lead to More https://thinkhazard.org/en/report/108-haiti/CF. Landslides?” Eos, November 23, 2020, doi: 10.1029/2020EO151418. 10 Government of Haiti, World Bank, IDB (Inter-American Development 27 Global Facility for Disaster Reduction and Recovery and Climate Bank), and UN (the United Nations System), 2010, Republic d’Haiti: Investment Fund. 2011. Vulnerability, Risk Reduction, and Adaptation to Analysis of Multiple Natural Hazards in Haiti (NATHAT), ReliefWeb, Climate Change. https://climateknowledgeportal.worldbank.org/sites/ March 26, 2010, https://reliefweb.int/report/haiti/analysis-multiple-natu- default/files/2018-10/wb_gfdrr_climate_change_country_profile_for_ ral-hazards-haiti-nathat. HTI.pdf. 11 The Emergency Events Database. https://public.emdat.be/. 28 David Alvarez Castro, 2013 ‘’Landslide Risks in Haiti and Land 12 Global Facility for Disaster Reduction and Recovery. Think Hazard. Management in Port au Prince,” Master’s thesis, Universidad Politécnica https://thinkhazard.org/en/report/108-haiti/CF . de Madrid. https://oa.upm.es/21673/2/TESIS_MASTER_DAVID_ ALVAREZ_CASTRO.pdf. 13 David Eckstein, Vera Kunzel, and Laura Schafer, 2021, Global Climate Risk Index 2021 — Who Suffers Most from Extreme Weather Events? 29 David Alvarez Castro, 2013 ‘’Landslide Risks in Haiti and Land Weather-Related Loss Events in 2019 and 2000–2019, ReliefWeb, Management in Port au Prince,” Master’s thesis, Universidad Politécnica January 2021, https://reliefweb.int/report/world/global-climate-risk-in- de Madrid. https://oa.upm.es/21673/2/TESIS_MASTER_DAVID_ dex-2021. ALVAREZ_CASTRO.pdf. 14 James M. Shultz, Toni Cela, Louis Herns Marcelin, Maria Espinola, Ilva 30 Global Facility for Disaster Reduction and Recovery and Climate Heitmann, Cludia Sanchez, Arielle Jean Pierre et al., 2016, “The Trauma Investment Fund. 2011. Vulnerability, Risk Reduction, and Adaptation to Signature of 2016 Hurricane Matthew and the Psychosocial Impact on Climate Change. https://climateknowledgeportal.worldbank.org/sites/ Haiti,” Disaster Health 3(4): 121–38, doi: 10.1080/21665044.2016.1263538. default/files/2018-10/wb_gfdrr_climate_change_country_profile_for_ HTI.pdf. 15 James M. Shultz, Toni Cela, Louis Herns Marcelin, Maria Espinola, Ilva Heitmann, Cludia Sanchez, Arielle Jean Pierre et al., 2016, “The Trauma 31 The Emergency Events Database. https://public.emdat.be/. Signature of 2016 Hurricane Matthew and the Psychosocial Impact on 32 The Emergency Events Database. https://public.emdat.be/. Haiti,” Disaster Health 3(4): 121–38, doi: 10.1080/21665044.2016.1263538. 33 Bhawan Singh, Marc J. Cohen. 2014. Climate Change Resilience: The 16 World Bank, 2020, Haiti: Providing Opportunities for all Haitians, case of Haiti. Oxam Research Reports. https://www-cdn.oxfam.org/ Results Brief, January 8, 2020, https://www.worldbank.org/en/ s3fs-public/file_attachments/rr-climate-change-resilience-haiti-260314- results/2020/01/08/haiti-providing-opportunities-for-all-haitians. en_2.pdf. 17 Erin Hulland, Saleena Subaiya, Katilla Pierre, Nikolson Barthelemy, 34 World Bank. Climate Change Knowledge Portal. https://climateknowl- Jean Samuel Pierre, Amber Dismer, Stanley Juin, David fitter, and Joan edgeportal.worldbank.org/. Brunkard, 2018, “Increase in Reported Cholera Cases in Haiti Following Hurricane Matthew: An Interrupted Time Series Model,” The American 35 World Bank. Climate Change Knowledge Portal. https://climateknowl- Journal of Tropical Medicine and Hygiene 100 (2): 368–73, doi: edgeportal.worldbank.org/. 10.4269/ajtmh.17-0964. 36 Intergovernmental Panel on Climate Change. WGI Interactive Atlas. 18 World Bank, 2020, Haiti: Providing Opportunities for all Haitians, https://interactive-atlas.ipcc.ch/. Results Brief, January 8, 2020, https://www.worldbank.org/en/ 37 Global Facility for Disaster Reduction and Recovery. Think Hazard. results/2020/01/08/haiti-providing-opportunities-for-all-haitians. https://thinkhazard.org/en/report/108-haiti/CF. 19 Macarthur Charles, Milo Richard, Mary R. Reichler, Jean Baptiste 38 Madeleine Rubenstein. 2012. Climate Change in Haiti. General Earth Koama, Willy Morose, and David L. Fitter, 2021, “Treatment Success for Institute. https://news.climate.columbia.edu/2012/02/01/climate-change- Patients with Tuberculosis Receiving Care in Areas Severely Affected in-haiti/. by Hurricane Matthew — Haiti, 2016,” PLoS One 16 (3): e0247750, doi: 10.1371/journal.pone.0247750. 39 Global Facility for Disaster Reduction and Recovery. Think Hazard. https://thinkhazard.org/en/report/108-haiti/CF. 20 World Bank, 2020, Haiti: Providing Opportunities for all Haitians, Results Brief, January 8, 2020, https://www.worldbank.org/en/ 40 Global Facility for Disaster Reduction and Recovery. Think Hazard. results/2020/01/08/haiti-providing-opportunities-for-all-haitians. https://thinkhazard.org/en/report/108-haiti/CF. 21 Jayaka D. Campbell, Michael A. Taylor, Arnoldo Bezanilla-Morlot, 41 République d’Haïti Ministère de la Santé Publique et de la Population, Tannecia S. Stephenson, Abel Centella-Artola, Leonardo A. Clarke, 2021, Plan Directeur Santé: 2021–2031, 7, HTI-111772.pdf (ilo.org). 57 42 Institute for Health Metrics and Evaluation. 2019. https://vizhub. 62 Global Hunger Index. 2019. Haiti: A closer look at hunger and healthdata.org/gbd-compare/. undernutrition. https://www.globalhungerindex.org/case-stud- ies/2019-haiti.html. 43 Institute for Health Metrics and Evaluation. 2019. https://vizhub. healthdata.org/gbd-compare/. 63 United States Agency of International Development. 2018. Haiti: Nutrition Profile. https://2017-2020.usaid.gov/sites/default/files/ 44 Institute for Health Metrics and Evaluation. 2019. https://vizhub. documents/1864/Haiti-Nutrition-Profile-Mar2018-508.pdf. healthdata.org/gbd-compare/. 64 International Trade Organization. Haiti Country Commercial Guide. 45 Peters, A., Schneider, A. Cardiovascular risks of climate change. Nat Rev https://www.trade.gov/country-commercial-guides/haiti-agricultural-sec- Cardiol 18, 1–2 (2021). https://doi.org/10.1038/s41569-020-00473-5. tor. 46 Michael Marmot Jessica Allen, Peter Goldblatt, Tammy Boyce, Di 65 Famine Early Warning Systems Network. 2021. Key Messages: Haiti. McNeish, Mike Grady, and Ilaria Geddes, 2010, Fair Society, Healthy https://fews.net/latin-america-and-caribbean/haiti/key-message-update/ Lives: The Marmot Review, https://www.instituteofhealthequity.org/ january-2022. resources-reports/fair-society-healthy-lives-the-marmot-review/fair-soci- ety-healthy-lives-full-report-pdf.pdf. 66 USAID, 2020, Haiti: Climate Risks to Resilience Food Security in Bureau for Humanitarian Assistance Geographies — Haiti, ReliefWeb, 47 The Emergency Events Database. https://public.emdat.be/. September 2020, https://reliefweb.int/report/haiti/haiti-climate-risks-re- 48 Institute for Health Metrics and Evaluation. 2019. https://vizhub. silience-food-security-bureau-humanitarian-assistance-geographies. healthdata.org/gbd-compare/. 67 Global Facility for Disaster Reduction and Recovery. Think Hazard. 49 World Bank. 2017. Rapidly Assessing the Impact of Hurricane Matthew in https://thinkhazard.org/en/report/108-haiti/CF. Haiti. https://www.worldbank.org/en/results/2017/10/20/rapidly-assess- 68 Mbow, C., C. Rosenzweig, L.G. Barioni, T.G. Benton, M. Herrero, M. ing-the-impact-of-hurricane-matthew-in-haiti. Krishnapillai, E. Liwenga, P. Pradhan, M.G. Rivera-Ferre, T. Sapkota, 50 World Bank. Climate Change Knowledge Portal. Country: Haiti. https:// F.N. Tubiello, Y. Xu, 2019: Food Security. In: Climate Change and climateknowledgeportal.worldbank.org/country/haiti/vulnerability. Land: an IPCC special report on climate change, desertification, land degradation, sustainable land management, food security, and 51 The Emergency Events Database. https://public.emdat.be/. greenhouse gas fluxes in terrestrial ecosystems [P.R. Shukla, J. Skea, 52 World Bank. Climate Change Knowledge Portal. Country: Haiti. https:// E. Calvo Buendia, V. Masson-Delmotte, H.-O. Pörtner, D.C. Roberts, climateknowledgeportal.worldbank.org/country/haiti/vulnerability. P. Zhai, R. Slade, S. Connors, R. van Diemen, M. Ferrat, E. Haughey, S. Luz, S. Neogi, M. Pathak, J. Petzold, J. Portugal Pereira, P. Vyas, 53 Republique D’ Haiti - Ministère De L’Environnement. 2006. Plan D’Action E. Huntley, K. Kissick, M. Belkacemi, J. Malley, (eds.)]. https://doi. National D’Adaptation (PANA). https://unfccc.int/resource/docs/napa/ org/10.1017/9781009157988.007. hti01f.pdf. 69 Smith, K.R. et al. 2014. Human Health: impacts, adaptation and 54 J. I. Macdiarmid and S. Whybrow S., 2019, “Nutrition from a Climate co-benefits. In: Climate Change 2014: Impacts, Adaptation, and Change Perspective,” Proceedings of the Nutrition Society 78 (3): Vulnerability. Part A: Global and Sectoral Aspects. Contribution of 380–7, doi: 10.1017/S0029665118002896. Working Group II to the Fifth Assessment Report of the Intergovernmen- 55 FAO (Food and Agriculture Organization of the United Nations), IFAD tal Panel on Climate Change. (International Fund for Agricultural Development), UNICEF (United 70 Institute for Health Metrics and Evaluation. 2019. https://vizhub. Nations Children’s Fund), WFP (World Food Programme), and WHO healthdata.org/gbd-compare/. (World Health Organization). The State of Food Security and Nutrition in the World — Transforming Food Systems for Food Security, Improved 71 United Nations International Children’s Emergency Fund. 2021. Haiti Nutrition, and Affordable Healthy Diets for all, Rome, Italy: FAO, doi: earthquake: over half million children at risk of waterborne diseases. 10.4060/cb4474en. https://www.unicef.org/lac/en/press-releases/haiti-earthquake-over-half- million-children-in-risk-of-waterborne-diseases. 56 Integrated Food Security Phase Classification (IPC). 2021. IPC Haiti Alert September 2021. https://www.ipcinfo.org/ipcinfo-website/alerts-archive/ 72 Erin Hulland, Saleena Subaiya, Katilla Pierre, Nikolson Barthelemy, issue-44/en/. Jean Samuel Pierre, Amber Dismer, Stanley Juin, David fitter, and Joan Brunkard, 2018, “Increase in Reported Cholera Cases in Haiti Following 57 Integrated Food Security Phase Classification (IPC). 2021. IPC Haiti Alert Hurricane Matthew: an Interrupted Time Series Model,” The American September 2021. https://www.ipcinfo.org/ipcinfo-website/alerts-archive/ Journal of Tropical Medicine and Hygiene 100 (2): 368–73, doi: issue-44/en/. 10.4269/ajtmh.17-0964. 58 Food and Agriculture Organization. 2021. The impact of disasters and 73 Levy K, Smith SM, Carlton EJ. Climate Change Impacts on Waterborne crises on agriculture and food security. https://www.fao.org/3/cb3673en/ Diseases: Moving Toward Designing Interventions. Curr Environ Health cb3673en.pdf. Rep. 2018 Jun;5(2):272-282. doi: 10.1007/s40572-018-0199-7. PMID: 59 Food and Agriculture Organization. 2021. The impact of disasters and 29721700; PMCID: PMC6119235. crises on agriculture and food security. https://www.fao.org/3/cb3673en/ 74 Kolstad EW, Johansson KA. Uncertainties associated with quantifying cb3673en.pdf. climate change impacts on human health: a case study for 60 Mbow, C., C. Rosenzweig, L.G. Barioni, T.G. Benton, M. Herrero, M. diarrhea. Environ Health Perspect. 2011 Mar;119(3):299-305. doi: Krishnapillai, E. Liwenga, P. Pradhan, M.G. Rivera-Ferre, T. Sapkota, 10.1289/ehp.1002060. Epub 2010 Oct 6. PMID: 20929684; PMCID: F.N. Tubiello, Y. Xu, 2019: Food Security. In: Climate Change and PMC3059990. Land: an IPCC special report on climate change, desertification, 75 United Nations International Children’s Emergency Fund. 2016. Race land degradation, sustainable land management, food security, and against time to prevent spread of waterborne diseases in hurricane-hit greenhouse gas fluxes in terrestrial ecosystems [P.R. Shukla, J. Skea, areas as rainy season starts in Haiti. https://www.unicef.org/ E. Calvo Buendia, V. Masson-Delmotte, H.-O. Pörtner, D.C. Roberts, press-releases/race-against-time-prevent-spread-waterborne-diseases- P. Zhai, R. Slade, S. Connors, R. van Diemen, M. Ferrat, E. Haughey, hurricane-hit-areas-rainy. S. Luz, S. Neogi, M. Pathak, J. Petzold, J. Portugal Pereira, P. Vyas, E. Huntley, K. Kissick, M. Belkacemi, J. Malley, (eds.)]. https://doi. 76 Erin Hulland, Saleena Subaiya, Katilla Pierre, Nikolson Barthelemy, org/10.1017/9781009157988.007. Jean Samuel Pierre, Amber Dismer, Stanley Juin, David fitter, and Joan Brunkard, 2018, “Increase in Reported Cholera Cases in Haiti Following 61 World Food Programme. 2016. Haiti Urban Food Security Assessment. Hurricane Matthew: An Interrupted Time Series Model,” The American https://documents.wfp.org/stellent/groups/public/documents/ena/ Journal of Tropical Medicine and Hygiene 100 (2): 368–73, doi: wfp287802.pdf?_ga=2.253165386.2130901058.1695244007- 10.4269/ajtmh.17-0964. 361008908.1695244007. 77 United Nations Office for the Coordination of Humanitarian Affairs. 2019. Haiti: Cholera figures (as of 26 December 2018). https://reliefweb.int/ report/haiti/haiti-cholera-figures-26-december-2018. 58 | Climate and Health Vulnerability Assessment: Haiti 78 Daniele Lantagne, G. Balakrish Nair, Claudio Lanata, and Alejandro 96 Boncy, P.J., Adrien, P., Lemoine, J.F. et al. Malaria elimination in Haiti by Cravioto, 2014, “The Cholera Outbreak in Haiti: Where and How Did It the year 2020: an achievable goal?. Malar J 14, 237 (2015). https://doi. Begin?” Current Topics in Microbiology and Immunology 379: 145–64, org/10.1186/s12936-015-0753-9. doi: 10.1007/82_2013_331. 97 Stephanie J. Salyer, Esther M. Ellis, Corvil Salomon, Christopher Bron, 79 Par Claudy Junior Pierre. 2022. Trois ans sans cholera, Haiti attend Stanley Juin, Ryan R. Hemme, and Elizabeth Hunsperger et al., 2014, son certificate d’élimination. Le Nouvelliste. https://lenouvelliste.com/ “Dengue Virus Infections among Haitian and Expatriate Non-Govern- article/234070/trois-ans-sans-cholera-haiti-attend-son-certificat-delimi- mental Organization Workers—Léogane and Port-au-Prince, Haiti, 2012,” nation.  PLoS Neglected Tropical Diseases 8 (10): e3269, doi: 10.1371/journal. pntd.0003269. 80 Cuellar-Martinez, T., Ruiz-Fernández, A. C., Alonso-Hernández, C., Amaya-Monterrosa, O., Quintanilla, R., Carrillo-Ovalle, H. L., Arbeláez 98 Meghan Rioth, Carole Anne Beauharnais, Francine Noel, Mine R. M, N., Díaz-Asencio, L., Méndez, S. M., Vargas, M., Chow-Wong, N. Ikizler, Sapna Mehta, Yuwei Zhu, Carole A. Long, Jean W. Pape, and F., Valerio-Gonzalez, L. R., Enevoldsen, H., & Dechraoui Bottein, M.-Y. Peter F. Wright, 2011, “Serologic Imprint of Dengue Virus in Urban Haiti: (2018). Addressing the Problem of Harmful Algal Blooms in Latin Characterization of Humoral Immunity to Dengue in Infants and Young America and the Caribbean- A Regional Network for Early Warning and Children,” The American Journal of Tropical Medicine and Hygiene 84 Response. Frontiers in Marine Science, 5. https://www.frontiersin.org/ (4): 630–6, doi: 10.4269/ajtmh.2011.10-0323. articles/10.3389/fmars.2018.00409. 99 Balthazard-Accou, K., François Millien, M., Michel, D., Jean, G., Telcy, 81 Paerl, H. W., Hall, N. S., & Calandrino, E. S. (2011). Controlling harmful D., & Emmanuel, E. 2021. Vector-Borne Diseases and Climate Change cyanobacterial blooms in a world experiencing anthropogenic and in the Environmental Context in Haiti. IntechOpen. doi: 10.5772/ climatic-induced change. Science of The Total Environment, 409(10), intechopen.96037. 1739–1745. https://doi.org/10.1016/j.scitotenv.2011.02.001. 100 Center for Disease Control and Prevention. Haiti - Chapter 10 - 2020 82 Haiti Libre. 2015. Haiti – ALERT: Algae invade the coast of the Great Yellow Book | Travelers’ Health. South. https://www.haitilibre.com/en/news-16193-haiti-alert-algae-in- 101 Maxime Chazal, Guillaume Beauclair, Ségolène Gracias, Valérie vade-the-coast-of-the-great-south.html. Najburg, Etienne Simon-Lorière, Frédéric Tangy, Anastassia V. 83 Haiti Libre. 2015. Haiti – ALERT: Algae invade the coast of the Great Komarova, and Nolwenn Jouvenet, 2018, “RIG-I Recognizes the 5′ South. https://www.haitilibre.com/en/news-16193-haiti-alert-algae-in- Region of Dengue and Zika Virus Genomes,” Cell Reports 24 (2): vade-the-coast-of-the-great-south.html. 320–8. 84 Andrea K Boggild, Mary Elizabeth Wilson. 2019. What every travel 102 Zika Virus—A Public Health Emergency of International Concern | medicine practitioner needs to know about Sargassum weed: five key Global Health | JAMA Neurology | JAMA Network. points, Journal of Travel Medicine, Volume 26, Issue 7, taz048, https:// 103 Ito Journel, Lesly L. Andrécy, Dudley Metellus, Jean S. Pierre, doi.org/10.1093/jtm/taz048. Rose Murka Faublas, Stanley Juin, Amber M. Dismer et al., 2017, 85 ANSES. 2018. Sargassum seaweed: limit the exposure of residents and “Transmission of Zika Virus — Haiti, October 12, 2015–September workers to hydrogen sulphide. https://www.anses.fr/en/content/sar- 10, 2016,” Morbidity and Mortality Weekly Report 66 (6): 172–6, doi: gassum-seaweed-limit-exposure-residents-and-workers-hydrogen-sul- 10.15585/mmwr.mm6606a4. phide. 104 Balthazard-Accou, K., François Millien, M., Michel, D., Jean, G., Telcy, 86 Kristie L. Ebi, Nicholas H. Ogden, Jan C. Semenza, and Alistair D., & Emmanuel, E. 2021. Vector-Borne Diseases and Climate Change Woodward, 2017, “Detecting and Attributing Health Burdens to Climate in the Environmental Context in Haiti. IntechOpen. doi: 10.5772/ Change,” Environmental Health Perspectives 125 (8): 85004, doi: intechopen.96037. 10.1289/EHP1509. 105 Kovats, R. S., & Hajat, S. (2008). Heat Stress and Public Health: A 87 Katie M. Westby, Solny A. Adalsteinsson, Elizabeth G. Biro, Alexis J. Critical Review. Annual Review of Public Health, 29(1), 41–55. https://doi. Beckermann, and Kim A. Medley, 2021, “Aedes Albopictus Populations org/10.1146/annurev.publhealth.29.020907.090843. and Larval Habitat Characteristics Across the Landscape: Significant 106 Qi Zhao, Shanshan Li, Micheline S. Z. S. Coelho, Paulo H. N. Saldiva, Differences Exist between Urban and Rural Land Use Types,” Insects 12 Kejia Hu, Rachel R. Huxley, Michael J. Abramson, and Yuming Guo, (3): 196, doi: 10.3390/insects12030196. 2019, “The Association between Heatwaves and Risk of Hospitalization 88 London School of Hygiene & Tropical Medicine. World Malaria Day 2021 in Brazil: A Nationwide Time Series Study between 2000 and 2015,” – Haiti. https://www.lshtm.ac.uk/research/centres/malaria-centre/world- PLOS Medicine 16 (2): e1002753, doi: 10.1371/journal.pmed.1002753. malaria-day-2021-haiti. 107 McGregor, G., Bone, A., & Pappenberger, F. 2017. Meteorological risk: 89 London School of Hygiene & Tropical Medicine. World Malaria Day 2021 extreme temperatures. In: Poljanšek, K., Marín Ferrer, M., De Groeve, – Haiti. https://www.lshtm.ac.uk/research/centres/malaria-centre/world- T., Clark, I. (Eds.), 2017. Science for disaster risk management 2017: malaria-day-2021-haiti . knowing better and losing less. EUR 28034 EN, Publications Office of the European Union, Luxembourg, ISBN 978-92-79-60678-6, 90 World Health Organization. 2021. World Malaria Report. https://www. doi:10.2788/688605, JRC102482. https://ghhin.org/wp-content/uploads/ who.int/teams/global-malaria-programme/reports/world-malaria-re- McGregor-et-al-2017-Extreme-Temperatures.pdf. port-2021. 108 World Health Organization. 2021. Climate Change and Health. https:// 91 Institute of Health Metrics and Evaluation. 2019. https://vizhub. www.who.int/news-room/fact-sheets/detail/climate-change-and-health. healthdata.org/gbd-compare/. 109 Intergovernmental Panel on Climate Change. WGI Interactive Atlas. 92 Center for Disease Control and Prevention. Haiti - Chapter 10 - 2020 https://interactive-atlas.ipcc.ch/. Yellow Book | Travelers’ Health. 110 Institute for Health Metrics and Evaluation. 2019. https://vizhub. 93 London School of Hygiene & Tropical Medicine. World Malaria Day 2021 healthdata.org/gbd-compare/ . – Haiti. https://www.lshtm.ac.uk/research/centres/malaria-centre/world- malaria-day-2021-haiti. 111 Berry, H.L., Waite, T.D., Dear, K.B.G. et al. The case for systems thinking about climate change and mental health. Nature Clim Change 8, 94 Boncy, P.J., Adrien, P., Lemoine, J.F. et al. Malaria elimination in Haiti by 282–290 (2018). https://doi.org/10.1038/s41558-018-0102-4. the year 2020: an achievable goal?. Malar J 14, 237 (2015). https://doi. org/10.1186/s12936-015-0753-9. 112 Thompson R, Hornigold R, Page L, Waite T. Associations between high ambient temperatures and heat waves with mental health outcomes: 95 Jules JR, Alencar J, Suárez-Mutis MC, Baptiste EJ, Albuquerque H, a systematic review. Public Health. 2018 Aug;161:171-191. doi: 10.1016/j. Rosa-Freitas MG, Raccurt C, Oliveira RL, Silva-do-Nascimento TF. puhe.2018.06.008. Epub 2018 Jul 12. PMID: 30007545. Malaria in Haiti: A descriptive study on spatial and temporal profile from 2009 to 2018. Rev Soc Bras Med Trop. 2022 Feb 25;55:e0355. doi: 10.1590/0037-8682-0355-2021. PMID: 35239903; PMCID: PMC8909436. References | 59 113 Thompson R, Hornigold R, Page L, Waite T. Associations between high 131 Institute for Health Metrics and Evaluation. 2019. https://vizhub. ambient temperatures and heat waves with mental health outcomes: healthdata.org/gbd-compare/. a systematic review. Public Health. 2018 Aug;161:171-191. doi: 10.1016/j. 132 Katie Hayes and Blake Poland, 2018, “Addressing Mental Health in a puhe.2018.06.008. Epub 2018 Jul 12. PMID: 30007545. Changing Climate: Incorporating Mental Health Indicators into Climate 114 Solomon M. Hsiang, Marshall Burke, and Edward Miguel, 2013, Change and Health Vulnerability and Adaptation Assessments,” “Quantifying the Influence of Climate on Human Conflict,” Science 341 International Journal of Environmental Research and Public Health 15 (6151), doi: 10.1126/science.1235367. (9): 1806, doi: 10.3390/ijerph15091806. 115 Obradovich N, Migliorini R, Mednick SC, Fowler JH. Nighttime 133 Clayton, S., Manning, C. M., Speiser, M., & Hill, A. N. 2021. Mental Health temperature and human sleep loss in a changing climate. Sci Adv. 2017 and Our Changing Climate: Impacts, Inequities, Responses. Washington, May 26;3(5):e1601555. doi: 10.1126/sciadv.1601555. PMID: 28560320; D.C.: American Psychological Association, and ecoAmerica. PMCID: PMC5446217. 134 Leah Emily James, Courtney Welton-Mitchell, John Roger Noel, and 116 Daniel J. Gottlieb, Naresh M. Punjabi, Ann B. Newman, Helaine E. Alexander Scott James, 2020, “Integrating Mental Health and Disaster Resnick, Susan Redline, Carol M. Baldwin, F. Javier Nieto, 2005, Preparedness in Intervention: A Randomized Controlled Trial with “Association of Sleep Time with Diabetes Mellitus and Impaired Glucose Earthquake and Flood-Affected Communities in Haiti,” Psychological Tolerance,” Archives of Internal Medicine 165 (8): 863–7, doi: 10.1001/ Medicine 50 (2): 342–52, Integrating mental health and disaster archinte.165.8.863. preparedness in intervention: a randomized controlled trial with earthquake and flood-affected communities in Haiti | Psychological 117 Najib T. Ayas, David P. White, JoAnn E. Manson, Meir J. Stampfer, Frank Medicine | Cambridge Core. E. Speizer, Atul Malhotra, Frank B. Hu, 2003, “A Prospective Study of Sleep Duration and Coronary Heart Disease in Women,” Archives of 135 World Health Organization. Mental Health Gap Action Programme. Internal Medicine 163 (2): 205–9, doi:10.1001/archinte.163.2.205. https://www.who.int/teams/mental-health-and-substance-use/ treatment-care/mental-health-gap-action-programme#:~:text=The%20 118 Chiara Baglioni, Gemma Battagliese, Bernd Feige, Kai Spiegelhalder, WHO%20Mental%20Health%20Gap,low%2D%20and%20middle%2Din- Christoph Nissen, Ulrich Voderholzer, Caterina Lombardo, and Dieter come. Riemann, 2011, “Insomnia as a Predictor of Depression: A Meta-Analytic Evaluation of Longitudinal Epidemiological Studies,” Journal of Affective 136 Elizabeth Rataj, Katharina Kunzweiler, amd Susan Garthus-Niegel, 2016, Disorders 135: 10–9, doi: 10.1016/j.jad.2011.01.011. “Extreme Weather Events in Developing Countries and Related Injuries and Mental Health Disorders — A Systematic Review,” BMC Public 119 Flavie Waters and Romola S. Bucks, 2011, “Neuropsychological Effects Health 16 (Article 1020), doi: 10.1186/s12889-016-3692-7. of Sleep Loss: Implication for Neuropsychologists,” Journal of the International Neuropsychological Society 17 (4): 571–86, doi: 10.1017/ 137 Shaohua Gu, Liang Zhang, Shiqiang Sun, Xiaofeng Wang, Beibei Lu, S1355617711000610. Hangtao Han, Jun Yang, and Aihong Wang, 2020, “Projections of Temperature-Related Cause-Specific Mortality under Climate Change 120 P. A. Hancock & I. Vasmatzidis (2003) Effects of heat stress on cognitive Scenarios in a Coastal City of China,” Environment International 143: performance: the current state of knowledge, International Journal of 105889, doi: 10.1016/j.envint.2020.105889. Hyperthermia, 19:3, 355-372, DOI: 10.1080/0265673021000054630. 138 Marshall Burke, Felipe González, Patrick Baylis, Sam Heft-Neal, Ceren 121 International Labour Organization. 2019. Working on a Warmer Planet: Baysan, Sanjay Basu, and Solomon Hsiang, 2018, “Higher Temperatures The impact of heat stress on labour productivity and decent work. Increase Suicide Rates in the United States and Mexico,” Nature https://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/--- Climate Change 8: 723–9, doi: 10.1038/s41558-018-0222-x. publ/documents/publication/wcms_711919.pdf. 139 Douglas Paton, 2006, “Posttraumatic Growth in Disaster and 122 International Labour Organization. 2019. Working on a Warmer Planet: Emergency Work,” in Handbook of Posttraumatic Growth: Research The impact of heat stress on labour productivity and decent work. and Practice, edited by Lawrence G. Calhoun and Richard G. https://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/--- Tedeschi, 225–47, New York, NY: Taylor and Francis Group, IJERPH publ/documents/publication/wcms_711919.pdf. | Free Full-Text | Addressing Mental Health in a Changing Climate: 123 Kahn Vohra, Alina Vodonos, Joel Schwartz, Eloise A. Marais, Melissa P. Incorporating Mental Health Indicators into Climate Change and Health Sulprizio, and Loretta J. Mickley, 2021, “Global Mortality from Outdoor Vulnerability and Adaptation Assessments | HTML (mdpi.com). Fine Particle Pollution Generated by Fossil Fuel Combustion: Results 140 Ken Hashimoto, Laure Adrien, and Sunil Rajkumar. 2020. “Moving from GEOS-Chem,” Environmental Research 195 (110754), doi: 10.1016/j. Towards Universal Health Coverage in Haiti,” Health Systems & Reform envres.2021.110754. 6 (1): e1719339, doi: 10.1080/23288604.2020.1719339. 124 Nick Watts, Markus Amann, Nigel Arnell, Sonja Ayeb-Karlsson, Kristine 141 Frontline Health Project. 2020. “The community health system in Haiti: Belesova, Maxwell Boykoff, Peter Byass et al., 2019, “The 2019 Report An overview,” brief. Washington, DC: Population Council. of The Lancet Countdown on Health and Climate Change: Ensuring that the Health of a Child Born Today is not Defined by a Changing Climate,” 142 Gouvernement de la République D’Haiti. Plan Stratégique de Lancet 394 (10211): 1836–78, doi: 10.1016/S0140-6736(19)32596-6. Développement D’Haiti: Pays Émergent en 2030. https://observato- rioplanificacion.cepal.org/sites/default/files/plan/files/Haiti_PLAN_ 125 (Gangoiti et al., 2001; Stohl et al., 2001; Buchanan et al., 2002; Chan et STRATÉGIQUE_de_developpement.pdf. al., 2002; Martin et al., 2002; Ryall et al., 2002; Ansmann et al., 2003; He et al., 2003; Helmis et al., 2003; Moore et al., 2003; Shinn et al., 143 United States Agency for International Development. 2020. Haiti 2003; Unsworth et al., 2003; Kato et al., 2004; Liang et al., 2004; Tu et Health Fact Sheet – January 2020. https://2017-2020.usaid.gov/ al., 2004). documents/1862/usaidhaiti-health-fact-sheet-january-2020. 126 Institute for Health Metrics and Evaluation. 2019. https://vizhub. 144 United States Agency for International Development. 2020. Haiti healthdata.org/gbd-compare/. Health Fact Sheet – January 2020. https://2017-2020.usaid.gov/ documents/1862/usaidhaiti-health-fact-sheet-january-2020. 127 Institute for Health Metrics and Evaluation. 2019. https://vizhub. healthdata.org/gbd-compare/. 145 Cavagnero, Eleonora Del Valle; Cros,Marion Jane; Dunworth,Ashleigh Jane; Sjoblom,Mirja Channa. 2017. Better spending, better care : a 128 Health Effects Institute, 2020, State of Global Air/2020: A Special look at Haiti’s health financing : summary report (English). Washington, Report on Global Exposure to Air Pollution and Its Health Impacts, D.C. : World Bank Group. http://documents.worldbank.org/curated/ Boston, MA: HEI, https://fundacionio.com/wp-content/uploads/2020/10/ en/393291498246075986/summary-report. soga-2020-report.pdf. 146 Johns Hopkins. Coronavirus Resource Center. https://coronavirus.jhu. 129 Health Effects Institute. 2020. State of Global Air 2020. Data source: edu/region/haiti. Global Burden of Disease Study 2019. IHME, 2020.. 147 World Health Organization. 2015. Operational framework for building 130 WHO published revised air quality guidelines on 22 September 2021 — climate resilient health systems. https://www.who.int/publications/i/item/ the first major update of standards in 15 years. operational-framework-for-building-climate-resilient-health-systems. 60 | Climate and Health Vulnerability Assessment: Haiti 148 Gouvernement de la République D’Haiti – Ministere de la Sante org/haiti-plan-strategique-de-developpement-des-ressources-hu- Publique et de la Population. 2012. Politique Nationale de Sante. https:// maines-pour-la-sante-2030/. mspp.gouv.ht/site/downloads/PNS%2021juillet%20version%20finale.pdf. 171 Gouvernement de la République D’Haiti – Ministère de la Santé 149 Climate Investment Funds. 2013. Strategic Program for Climate publique et de la population. 2017. Plan Stratégique de Développement Resilience for Haiti. https://www.cif.org/sites/default/files/PPCR_ des Ressources Humaines pur la Santé 2030. https://www.hfgproject. SC.12_4_Strategic_Program_for_Climate_Resilience_for_Haiti..pdf. org/haiti-plan-strategique-de-developpement-des-ressources-hu- maines-pour-la-sante-2030/. 150 Climate Investment Funds. Haiti. https://www.cif.org/country/haiti. 172 Gouvernement de la République D’Haiti – Ministère de la Santé 151 Gouvernement de la République D’Haiti – Ministere De L’Environne- publique et de la population. 2015. Liste des Institutions Sanitaires ment. Deuxieme Communication Nationale Sur Les Changements du Pays. https://mspp.gouv.ht/site/downloads/Liste%20des%20 Climatiques. Institutions%20Sanitaires%202015.pdf. 152 http://energyaccess.org/wp-content/uploads/2015/05/Haiti-Road- 173 Ken Hashimoto, Laure Adrien, and Sunil Rajkumar, 2020, “Moving map-French-Publication-file.pdf. Towards Universal Health Coverage in Haiti,” Health Systems & Reform 153 Gouvernement de la République D’Haiti. Intended Nationally 6 (1): e1719339, doi: 10.1080/23288604.2020.1719339. Determined Contributions (INDCs). https://www4.unfccc.int/sites/ 174 Andrew MacCalla. 2013. Training Skilled Birth Attendants in Haiti. submissions/indc/Submission%20Pages/submissions.aspx. DirectRelief. https://www.directrelief.org/2013/01/training-skilled-birth-at- 154 Gouvernement de la République D’Haiti – Ministere De L’Environne- tendants-haiti/. ment. Plan D’Action National D’Adaptation (PANA). https://unfccc.int/ 175 Ken Hashimoto, Laure Adrien, and Sunil Rajkumar, 2020, “Moving resource/docs/napa/hti01f.pdf. Towards Universal Health Coverage in Haiti,” Health Systems & Reform 155 UNDP. 2018. National Adaptation Plans in Focus: Lessons from Haiti. 6 (1): e1719339, doi: 10.1080/23288604.2020.1719339. https://www.ldc-climate.org/wp-content/uploads/2018/07/haiti_nap_ 176 Ken Hashimoto, Laure Adrien, and Sunil Rajkumar, 2020, “Moving country_briefing_final_online1.pdf. Towards Universal Health Coverage in Haiti,” Health Systems & Reform 156 Global Environment Facility. 2009. Haiti: Strengthenind Adaptive 6 (1): e1719339, doi: 10.1080/23288604.2020.1719339. Capacities to Address Climate Change Threats on Sustainable 177 Partners in Health. Haiti. https://www.pih.org/country/haiti?ms=lb. Development Strategies for Coastal Communities. https://www. uncclearn.org/wp-content/uploads/library/gef41_0.pdf. 178 Valery M. Beau de Rochars, Jean Claude Cadet, and Arch G. Mainous 3rd, 2018, “Global Health: A View from the School of Medicine of 157 Climate Funds Update. Pilot Program for Climate Resilience. https://cli- L’Université d’État d’Haïti,” Family Medicine 50 (4), 259–61. doi: matefundsupdate.org/the-funds/pilot-program-for-climate-resilience-2/. 10.22454/FamMed.2018.363441. 158 United Nations Development Program. 2018. National Adaptation Plan 179 Health Finance & Governance Project. 2012. HFG Haiti Final Report. in Focus. https://www.ldc-climate.org/wp-content/uploads/2018/07/ https://www.hfgproject.org/hfg-haiti-final-country-report/. haiti_nap_country_briefing_final_online1.pdf. 180 Gouvernement de la République D’Haiti – Ministère de la Santé 159 United Nations Development Program. 2018. National Adaptation Plan publique et de la population. 2017. Plan Stratégique de Développement in Focus. https://www.ldc-climate.org/wp-content/uploads/2018/07/ des Ressources Humaines pur la Santé 2030. https://www.hfgproject. haiti_nap_country_briefing_final_online1.pdf. org/haiti-plan-strategique-de-developpement-des-ressources-hu- 160 Gouvernement de la République D’Haiti – Ministere De L’Environne- maines-pour-la-sante-2030/. ment. 2019. Politique Nationale de Lutte Contre Les Changements 181 Health Finance & Governance Project. Haiti Health Workforce Data Climatiques. https://mde.gouv.ht/phocadownload/PNCC-HAITI-2019%20 Audits to Human Resources for Health Improvements. https://www. Final.pdf. hfgproject.org/health-workforce-data-audits-lead-improvements-hu- 161 Gouvernement de la République D’Haiti. 2019. Plan National de Gestion man-resources-health-haiti/. des Risques de Désastre 2019 – 2030. https://www.preventionweb.net/ 182 Health Finance & Governance Project. 2012. HFG Haiti Final Report. files/72907_plannationaldegestiondesrisquesdeds.pdf. https://www.hfgproject.org/hfg-haiti-final-country-report/. 162 Gouvernement de la République D’Haiti – Ministère de la Santé 183 Panamerican Health Organization. Health Information Systems. https:// publique et de la population. 2021. Plan Directeur Santé (2021-2031). www3.paho.org/ish/index.php/en/. https://www.ilo.org/dyn/natlex/natlex4.detail?p_lang=en&p_ isn=111772&p_count=5&p_classification=01. 184 Ministère de L’Intérieur et des Collectivités Territoriales & Ministère de la Planification et de la Coopération Extreme, 2019, Plan National 163 USD13,475,000 of USD980,015,184, or 1.37 percent. de Gestion des Risques de Desastre 2019-2030, République d’Haïti, 164 Whitney Joseph. (n.d.) The Effect of Brain Drain on Haiti. https://api. https://www.undp.org/sites/g/files/zskgke326/files/migration/ht/Annexe- drum.lib.umd.edu/server/api/core/bitstreams/ec94a237-6cdf-4c9a- 3---PNGRD-2019-2030.pdf. abb9-693162b42a0f/content. 185 HaitiData. Webpage resource: https://haitidata.org/. 165 United States Agency for International Development. 2020. Haiti 186 Lowrance DW, Tappero JW, Poncelet JL, Etienne C, Frieden TR, Health Fact Sheet – January 2020. https://2017-2020.usaid.gov/ Delsoins D. Public Health Progress in Haiti. Am J Trop Med Hyg. 2017 documents/1862/usaidhaiti-health-fact-sheet-january-2020. Oct;97(4_Suppl):1-3. doi: 10.4269/ajtmh.17-0347. PMID: 29064358; 166 World Health Organization. 2016. Health Workforce Requirements for PMCID: PMC5676629.. Universal Health Coverage and the Sustainable Development Goals. 187 Lowrance DW, Tappero JW, Poncelet JL, Etienne C, Frieden TR, https://iris.who.int/bitstream/handle/10665/250330/9789241511407-eng. Delsoins D. Public Health Progress in Haiti. Am J Trop Med Hyg. 2017 pdf. Oct;97(4_Suppl):1-3. doi: 10.4269/ajtmh.17-0347. PMID: 29064358; 167 World Health Organization. Global Health Observatory data repository. PMCID: PMC5676629.. https://apps.who.int/gho/data/node.main.HWFGRP_0180?lang=en. 188 Health Finance & Governance Project. 2014. The Essential Package of 168 World Health Organization. Global Health Observatory data repository. Health Services and Health Benefit Plans in Haiti. https://pdf.usaid.gov/ https://apps.who.int/gho/data/node.main.HWFGRP_0180?lang=en. pdf_docs/PA00MTRF.pdf. 169 Ken Hashimoto, Laure Adrien, and Sunil Rajkumar, 2020, “Moving 189 Lowrance DW, Tappero JW, Poncelet JL, Etienne C, Frieden TR, Towards Universal Health Coverage in Haiti,” Health Systems & Reform Delsoins D. Public Health Progress in Haiti. Am J Trop Med Hyg. 2017 6 (1): e1719339, doi: 10.1080/23288604.2020.1719339. Oct;97(4_Suppl):1-3. doi: 10.4269/ajtmh.17-0347. PMID: 29064358; PMCID: PMC5676629.. 170 Gouvernement de la République D’Haiti – Ministère de la Santé publique et de la population. 2017. Plan Stratégique de Développement des Ressources Humaines pur la Santé 2030. https://www.hfgproject. References | 61 190 United States Agency for International Development. 2020. Haiti 209 Kelly Sims Gallagher, Keston Perry, Mieke van der Wansem, Laura Kuhl, Health Fact Sheet – January 2020. https://2017-2020.usaid.gov/ and Laurent Frapaise, 2019, Analysis of International Funding for Haiti’s documents/1862/usaidhaiti-health-fact-sheet-january-2020. Climate Change Priorities, Social Science Research Network, doi: 10.2139/ssrn.3333173. 191 Ken Hashimoto, Lauré Adrien & Sunil Rajkumar. 2020. Moving Towards Universal Health Coverage in Haiti, Health Systems & Reform, 6:1, DOI: 210 Health Policy Project. 2016. Health Financing Profile: Haiti. https://www. 10.1080/23288604.2020.1719339. healthpolicyproject.com/pubs/7887/Haiti_HFP.pdf. 192 Ken Hashimoto, Lauré Adrien & Sunil Rajkumar. 2020. Moving Towards 211 Health Policy Project. 2016. Health Financing Profile: Haiti. https://www. Universal Health Coverage in Haiti, Health Systems & Reform, 6:1, DOI: healthpolicyproject.com/pubs/7887/Haiti_HFP.pdf. 10.1080/23288604.2020.1719339. 212 Health Policy Project. 2016. Health Financing Profile: Haiti. https://www. 193 Saria Hassan, Mytien Nguyen, Morgan Buchanan, Alyssa Grimshaw, healthpolicyproject.com/pubs/7887/Haiti_HFP.pdf. Oswald P. Adams, Trevor Hassell, LaVerne Ragster, and Marcella 213 Health Policy Project. 2016. Health Financing Profile: Haiti. https://www. Nunez-Smith, 2020, “Management Of Chronic Noncommunicable healthpolicyproject.com/pubs/7887/Haiti_HFP.pdf. Diseases After Natural Disasters In The Caribbean: A Scoping Review,” Health Affairs 39 (12): 2136–43, doi: 10.1377/hlthaff.2020.01119. 214 Kelly Sims Gallagher, Keston Perry, Mieke van der Wansem, Laura Kuhl, and Laurent Frapaise, 2019, Analysis of International Funding for Haiti’s 194 Gouvernement de la République D’Haiti – Ministère de la Santé Climate Change Priorities, Social Science Research Network, doi: publique et de la population. 2015. Liste des Institutions Sanitaires 10.2139/ssrn.3333173. du Pays. https://mspp.gouv.ht/site/downloads/Liste%20des%20 Institutions%20Sanitaires%202015.pdf. 215 Gallagher, Kelly Sims and Perry, Keston K. and van der Wansem, Mieke and Kuhl, Laura and Frapaise, Laurent. 2019. Analysis of International 195 Commune: a subdivision of a department. Funding for Haiti’s Climate Change Priorities. Available at: https://ssrn. 196 Gouvernement de la République D’Haiti – Ministère de la Santé com/abstract=3333173 or http://dx.doi.org/10.2139/ssrn.3333173. publique et de la population. 2018. Enquête Mortalité, Morbidité et 216 Gallagher, Kelly Sims and Perry, Keston K. and van der Wansem, Mieke Utilisation des Services EMMUS-VI, Port-au-Prince (Haiti): MSPP. and Kuhl, Laura and Frapaise, Laurent. 2019. Analysis of International 197 Ken Hashimoto, Laure Adrien, and Sunil Rajkumar, 2020, “Moving Funding for Haiti’s Climate Change Priorities. Available at: https://ssrn. Towards Universal Health Coverage in Haiti,” Health Systems & Reform com/abstract=3333173 or http://dx.doi.org/10.2139/ssrn.3333173. 6 (1): e1719339, doi: 10.1080/23288604.2020.1719339. 217 Gallagher, Kelly Sims and Perry, Keston K. and van der Wansem, Mieke 198 Lia I. Losonczy, Sean L. Barnes, Shiping Liu, Sarah R. Williams, Michael and Kuhl, Laura and Frapaise, Laurent. 2019. Analysis of International T. McCurdy, Vivienne Lemos, Jerry Chandler et al., 2019, “Critical Care Funding for Haiti’s Climate Change Priorities. Available at: https://ssrn. Capacity in Haiti: A Nationwide Cross-Sectional Survey,” PLOS ONE 14 com/abstract=3333173 or http://dx.doi.org/10.2139/ssrn.3333173. (6): e0218141, doi: 10.1371/journal.pone.0218141. 218 World Bank. 2020. World Bank Group Strategy for Fragility, Conflict, 199 Ministère de L’Intérieur et des Collectivités Territoriales & Ministère and Violence 2020-2025. https://documents1.worldbank.org/curated/ de la Planification et de la Coopération Extreme. 2019. Plan National en/844591582815510521/pdf/World-Bank-Group-Strategy-for-Fragili- de Gestion des Risques de Desastre 2019-2030, République d’Haïti, ty-Conflict-and-Violence-2020-2025.pdf. https://www.undp.org/sites/g/files/zskgke326/files/migration/ht/ 219 Haiti - Environment and Global Climate Change - Country Dashboard An¬nexe-3---PNGRD-2019-2030.pdf. - All (usaid.gov). Description of data —“Mortality rate attributed 200 Ministère de L’Intérieur et des Collectivités Territoriales & Ministère to household and ambient air pollution is the number of deaths de la Planification et de la Coopération Extreme, 2019, Plan National attributable to the joint effects of household and ambient air pollution de Gestion des Risques de Desastre 2019-2030, République d’Haïti, in a year per 100,000 population. The rates are age-standardized. https://www.undp.org/sites/g/files/zskgke326/files/migration/ht/Annexe- Following diseases are taken into account: acute respiratory infections 3---PNGRD-2019-2030.pdf. (estimated for all ages); cerebrovascular diseases in adults (estimated above 25 years); ischemic heart diseases in adults (estimated above 201 Ministère de L’Intérieur et des Collectivités Territoriales & Ministère 25 years); chronic obstructive pulmonary disease in adults (estimated de la Planification et de la Coopération Extreme, 2019, Plan National above 25 years); and lung cancer in adults (estimated above 25 years).” de Gestion des Risques de Desastre 2019-2030, République d’Haïti, https://www.undp.org/sites/g/files/zskgke326/files/migration/ht/Annexe- 220 United States Agency for International Development. 2020. Haiti: 3---PNGRD-2019-2030.pdf. Climate Risks to Resilience Food Security in Bureau for Humanitarian Assistance Geographies — Haiti, ReliefWeb, September 2020, https:// 202 United States Agency for International Development. 2020. Haiti reliefweb.int/report/haiti/haiti-climate-risks-re¬silience-food-security-bu- Health Fact Sheet – January 2020. https://2017-2020.usaid.gov/ reau-humanitarian-assistance-geographies. documents/1862/usaidhaiti-health-fact-sheet-january-2020. 203 Cavagnero,Eleonora Del Valle; Cros,Marion Jane; Dunworth,Ashleigh Jane; Sjoblom,Mirja Channa. 2017. Better spending, better care : a look at Haiti’s health financing : summary report (English). Washington, D.C. : World BankGroup. http://documents.worldbank.org/curated/ en/393291498246075986/summary-report. 204 Ken Hashimoto, Laure Adrien, and Sunil Rajkumar, 2020, “Moving Towards Universal Health Coverage in Haiti,” Health Systems & Reform 6 (1): e1719339, doi: 10.1080/23288604.2020.1719339. 205 Ken Hashimoto, Laure Adrien, and Sunil Rajkumar, 2020, “Moving Towards Universal Health Coverage in Haiti,” Health Systems & Reform 6 (1): e1719339, doi: 10.1080/23288604.2020.1719339. 206 World Bank. Current health expenditure (% of GDP) – Haiti. https://data. worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locations=HT. 207 World Bank. Current health expenditure (% of GDP) – Haiti. 208 United States Agency for International Development. 2014. Developing Haiti’s First Health Financing Strategy, Health Finance & Governance, https://www.hfgproject.org/wp-content/ uploads/2014/06/Develop- ing-Haitis-First-Health-Financing-Strate¬gy-Brief.pdf. 62 | Climate and Health Vulnerability Assessment: Haiti References | 63 MARCH 2024 64 | Climate and Health Vulnerability Assessment: Haiti