Despite lax rules, COVID-19 claims few lives in Haiti. Scientists want to know why.

In Haiti, they are acting like COVID-19 doesn’t exist.

Mask-wearing is an exception and not the norm; bands are playing to sold-out crowds; and Kanaval, the three-day pre-Lenten debauchery-encouraging street party is back on for February.

This is not a case of a population simply in denial. In a country of roughly 11 million people, there have been an astoundingly low 234 confirmed deaths related to the novel coronavirus. Across the border in the neighboring Dominican Republic, with roughly the same population, the pandemic has killed almost ten times the number, 2,364. Jet off to Miami-Dade County, home to one of the larger Haitian communities in the United States, and the death toll is even higher: 4,002 in a population of 2.7 million.

What’s going on? Nobody is sure.

“We don’t have a large quantity of people who are in bad shape,” said Dr. Sophia Cherestal Wooley, deputy medical coordinator for Doctors Without Borders/Médecins Sans Frontières in Port-au-Prince. “They don’t get sick to the point that they need to be hospitalized and we don’t have the same quantity of people who have died here like in the Dominican Republic.

“Sincerely, I don’t have an explanation as to why,” she said. “We cannot say that the virus isn’t in circulation and I don’t think Haiti has a different virus that’s circulating. It’s the same as the others because there have been no studies saying otherwise.”

Shortly after the first imported case of COVID-19 was confirmed in Haiti on March 19, epidemiologists raised alarms. Taking into account Haiti’s weak health system, crowded living conditions and the population’s skepticism about the virus, they feared that the country, which has seen so much tragedy, would be overwhelmed by COVID-19 infections.

At best, there would be 2,000 deaths, the models predicted. At worst, around 20,000.

Even the Pan American Health Organization, citing a surge of Haitians crossing the border from the Dominican Republic to escape a spike there and the country’s ongoing political and humanitarian crises, voiced concerns about a pending crisis.

But fears that the deadly pandemic could unleash civil unrest and an even deeper humanitarian crisis have so far not proven accurate.

“Today Haiti has been mildly affected compared to other countries in the region,” Dr. Sylvain Aldighieri, incident manager at the Pan American Health Organization, said. “But the collateral effects, the socioeconomics, health and nutritional are considerable.”

Still, the low number of deaths is especially surprising because of the government’s own chaotic response and lax enforcement of its own rules.

Ministry of Health surveillance data show that Haiti experienced a first peak at the end of May into early June, and hospitalizations, while rising at one point, never reached critical levels.

In late August, a month before the U.S. government handed over 37 ventilators to the country to respond to COVID-19, Doctors Without Borders/Médecins Sans Frontières closed its COVID-19 treatment center after only three months of operation. In recent months, other units have also closed, and plans to turn local soccer stadiums into oversized hospitals, never materialized.

Though public health experts are relieved about the death toll, they also warn that other health indicators suggest the country is not out of the woods.

“What we have to remember is that we are confronting a deadly disease, a new virus that probably has not yet manifested itself fully,” said Dr. Jean Hughes Henrys, a member of the government-backed scientific commission supporting the COVID-19 response. “We have to remain vigilant.”

On Monday, Haiti reported a total of 9,588 confirmed cases since March. In comparison, the Dominican Republic has registered 155,000 infections.

This week, health workers on the front lines of the pandemic were warned that the country may be heading into a second wave. Not only is the country experiencing an uptick in laboratory confirmed cases, but the positivity rate has gone from almost 9 percent in November to almost 16 percent last week. The majority of the cases are coming mostly from the United States, particularly Florida, and the Dominican Republic.

“Does that mean people should be panicked? I don’t believe panicking solves anything,” said Henrys, who is also director of laboratory research at Port-au-Prince’s Quisqueya University and coordinator of post-graduate health sciences programs. “But it’s a good reason to reinforce vigilance and reinforce the measures of prevention … because the rising tendency could possibly invite a second peak.”

So far, those words are falling on deaf ears in the country where public transports, church pews and nightclubs are back to crowded conditions, and Haitians are pouring in for the holidays from abroad.

The reason for the laissez-faire attitude, which still may be rooted in skepticism and stigma, also comes from the fact that Haitians are still only presenting mild symptoms when they get infected. Why is part of the medical and scientific mystery.

“The reason for the lower incidence of detected COVID-19 is not completely clear,” Aldighieri said. “Nevertheless it’s important to point out that the virus continues to circulate in the country. It means that the risk is there; there are cases every day being confirmed by the laboratory in Haiti.”

PAHO, he said, plans to help Haiti with testing by supporting a plan to have nurses visit remote areas, and take samples using 40 testing sites currently located around the country. PAHO also plans to provide rapid antigen test kits as part of an ongoing population-based study to try and figure out what percentage of Haitians may have been exposed to COVID by checking for antibodies from a past infection.

In the meantime, Aldighieri said PAHO “is recommending strengthening surveillance, contact tracing especially in some areas.”

Though there has yet to be a definitive study on why Haitians are not falling ill as rapidly as others and only showing mild symptoms when they do get infected, several theories are being discussed and explored. They range from genetic makeup to age of the population.

Mary A. Clisbee, the director of research for Zanmi Lasante, which runs the University Hospital of Mirebalais, said scientists and doctors regularly discuss the surprise evolution of COVID-19 in Haiti and have tossed around several explanations for the seemingly low infection and mortality rates.

But there is still one nagging question she and others do not know the answer to.

“We really do not have any idea right now of the prevalence of COVID-19 in the country; nor do we know what percentage of the population has had COVID,” Clisbee said.

Like everything else in Haiti, the COVID situation is very complex, said Clisbee, and Zanmi Lasante is conducting social science research investigating how public attitudes about institutional healthcare may be affecting the official statistics.

“You have widespread distrust of the healthcare system, so there are lots of health-seeking behaviors that are based on these kinds of rumors that come from distrust,” she said. “People are concerned if they go to the hospital that they’re going to be given a shot that gives them COVID or if they go to the hospital they will get COVID from the hospital. So people, widely, have not presented to hospitals for treatment for their COVID symptoms, which means they are not tested.”

But avoiding doctors doesn’t explain the minuscule death rate. One working theory for that: Haiti has a young population and fewer people with underlying health conditions, which make individuals with COVID-19 much likelier to die.

“More than half of the population is under the age of 24,” said Clisbee, who has a doctoral degree in education. “So the people in that age bracket haven’t been the people who have been dying. They get sick but they don’t get really sick or they are just asymptomatic entirely. That explains a good number of cases in Haiti, we just really have a young population.”

Even anecdotally, the country isn’t seeing the kind of death toll it saw just 10 years ago when cholera hit, and medical professionals were overwhelmed with corpses and deathly ill patients.

“We haven’t had any of that,” Clisbee said. “We do know that even if the prevalence rate is really high in the provinces that the death rate has not been high. That makes you stop to say, ‘Why might that be?’ “

Clisbee, who resides in a rural province in the north, said the official number of COVID-19 infections would lead one to believe that the disease is only spreading in Port-au-Prince. But it is common, she said, to hear people in the rural outskirts say, “Yeah everybody had it up here. Everybody got the flu and they got a fever for a couple of days, but we drank our tea and then we were fine.”

“But they are young. That’s one part of it. The age distribution in Haiti is different,” she said. “Another difference is that in [the U.S.] people who have those diseases, heart disease, high blood pressure, diabetes, we extend their life by giving them good health treatment. Well in Haiti, people don’t have access to that treatment. … If you’re elderly and you have a disease, you die if you live in the provinces.”

As for the teas and other natural remedies, scientists have found no medical evidence that they work. But there is a strong belief among Haitians in plant-based home brews and that the ones used to fight malaria and reduce fevers are also good for COVID.

Dr. Jean William “Bill” Pape, the co-chair of the presidential COVID-19 response commission, welcomes the continued support of PAHO. Pape said his own GHESKIO health research and training facility in Port-au-Prince has temporarily closed its two COVID-19 units for lack of patients, “but they can be reactivated within a few hours if needed.”

While he remains concerned that Haiti may enter a second wave due to the increased migratory patterns around the holidays, Pape noted it is not the only country, thus far, spared by COVID-19. “Most of the Caribbean and equatorial Africa, many Asian and Middle Eastern countries are in similar situations.”

Several eastern Caribbean countries have successfully kept COVID-19 at bay. But unlike Haiti, their populations are smaller and they have continued to enforce strict COVID-19 restrictions like caps on the number of people who can gather in public, or attend funerals. They also enforce testing and/or 14-day quarantine requirements for travelers, which Haiti does not enforce.

And then there is the matter of wearing masks. After announcing in May that wearing a mask in public was mandatory, the government has since backed off. In fact with no scary spikes in deaths, measures began relaxing in July after the government opted not to extend a national state of emergency and reopened schools, churches and international borders.

The reality on the streets has been large gatherings, no social distancing, and few face coverings.

“This is not our recommendation,” Pape said about the absence of masks. “The government is preaching by example by making the use of masks mandatory in all public institutions.”

Maybe so. But it is also a government of contradictions. While continuing to call on Haitians to practice social distancing, it has allowed businesses and nightclubs to operate without restrictions, while ignoring the advice of its own scientific experts.

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