(2024) Climate and Health Vulnerability Assessment: Haiti

Climate and Health Vulnerability Assessment HAITI Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized © 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 iv | Climate and Health Vulnerability Assessment: Haiti 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 Contents | v 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 vi | Climate and Health Vulnerability Assessment: Haiti 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 Acknowledgments | vii 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. viii | Climate and Health Vulnerability Assessment: Haiti 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 List of Abbreviations | ix 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   1 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. 2 | Climate and Health Vulnerability Assessment: Haiti 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. 3 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 Haiti’s vulnerability to fragility, conflict, and violence (FCV), further magnifying 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 conflicts. 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. AIMS OF ASSESSMENT AND CONCEPTUAL FRAMEWORK 3. The objective of this Climate and Health Vulnerability Assessment (CHVA) is to assist decision-makers with planning effective adaptation measures to deal with climate- related health risks. Where available, these measures are also provided at the subnational level to assist regional health planners. The recommendations of this CHVA are primarily aimed at the health sector; however, related sectors influencing health risks that stem from climate changes, such as DRM, are also included. The target audience includes, but is not limited to, the country’s Ministry of Health, Ministry of Environment, and any other ministry involved in addressing climate-related health risks, as well as nongovernmental organiza- tions (NGOs) that are involved in supporting projects and programs for the health system in Haiti. 4. Adaptation priorities need to run alongside fundamental and urgent action to mitigate 4 | Climate and Health Vulnerability Assessment: Haiti climate change. It is important to stress how complex the climate challenge is and how hard it is to predict with accuracy how severe climate exposures facing populations will become. There are many factors that could slightly slow or significantly speed up the rates of change, including positive feedback effects and, most worrying of all, cascading climatological tipping points. For this reason, mitigating existing greenhouse gas emissions (GHGs), as well as developing and implementing measures to protect human development from the changing climate, is of paramount importance. 5. Investing in adaptation strategies to proactively address the effects of climate change on health outcomes is critical. This assessment is focused on the climate risks to health and health systems, the adaptive capacities in place to deal with these risks, and the recommendations to meet identified gaps. The primary focus of this assessment is, therefore, on climate adaptation and resilience measures. However, as the Assessment Report Six (AR6) 1 of the Intergovernmental Panel on Climate Change (IPCC) makes clear, “Global surface temperature will continue to increase until at least the mid-century under all emissions scenarios considered.” Mitigation is no longer a sufficient strategy, regardless of the pace of the response of governments and communities around the world. Adaptation is now as critical a part of climate action as mitigation. Therefore, although this report is focused on adaptation measures, it also includes recommendations on reducing the healthcare sector’s carbon footprint. 6. The World Health Organization’s (WHO) operational framework for building climate-re- silient health systems is adopted to analyze the adaptive capacity to adequately deal with current and future identified risks. Based on this framework (Figure 1), the assessment is structured around the six health systems strengthening (HSS) building blocks. These six categories offer a structure for organizing the assessment of capacities and gaps — now and into the future. The framework then moves on to consider WHO’s operational framework to develop the Recommendations section. 7. This assessment follows a stepwise linear approach. The first step characterizes the climatology in Haiti — highlighting the observed and future climate exposures relevant to health. The second step examines climate-related health risks, including identifying vulnerable populations. The final step assesses the adaptive capacity of the health system — identifying gaps for the management of current and future climate-re- lated health risks. Together, these steps inform a series of recommendations for reducing climate-related health vulnerability in Haiti. The assessment is based on a review of the published literature, as well as national and international quantitative and qualitative data. 8. The assessment incorporates subnational considerations for health-related climate action. Within the context of this assessment, 10 administrative departments of Haiti were considered: Artibonite, Centre, Grand’Anse, Nippes, Nord, Nord-Est, Nord-Ouest, Ouest, Sud-Est, and Sud (Figure 2). FIGURE 1. World Health Organization (WHO) operational framework for climate-resilient healthcare systems CLIMATE RESILIEN C E Leadership & Governance Health Workfo rc e H e a lt h F in a n c i n g C lim a te   & P r e p a r e d n e s s  & M a n a g e m e n t E m e r g e n c y H e a l t h I n f o r m e d C l i m a t e - P r o g r a m s D e trim ents E n v iro nm ental M a n a g em ent of o f H ealth Technologies& SustainableClimate Resilient & Infrastructure C lim a te   H e a lth  & R e se a rc h M o n it o r in g  & E a r ly  W a r n in g I n t e g r a t e d  R is k C a p a c i t y   & A d a p t a t i o n A s s e s s m e n t V u l n e r a b i l i t y , Service Delivery Financing Health Workforce Health Information Systems Essential Medical Products & Technologies Leadership & Governance BUILDING BLOCKS OF HEALTH SYSTEMS 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 6. The World Health Organization’s (WHO) operational framework for building climate-re- silient health systems is adopted to analyze the adaptive capacity to adequately deal with current and future identified risks. Based on this framework (Figure 1), the assessment is structured around the six health systems strengthening (HSS) building blocks. These six categories offer a structure for organizing the assessment of capacities and gaps — now and into the future. The framework then moves on to consider WHO’s operational framework to develop the Recommendations section. 7. This assessment follows a stepwise linear approach. The first step characterizes the climatology in Haiti — highlighting the observed and future climate exposures relevant to health. The second step examines climate-related health risks, including identifying vulnerable populations. The final step assesses the adaptive capacity of the health system — identifying gaps for the management of current and future climate-re- lated health risks. Together, these steps inform a series of recommendations for reducing climate-related health vulnerability in Haiti. The assessment is based on a review of the published literature, as well as national and international quantitative and qualitative data. 8. The assessment incorporates subnational considerations for health-related climate action. Within the context of this assessment, 10 administrative departments of Haiti were considered: Artibonite, Centre, Grand’Anse, Nippes, Nord, Nord-Est, Nord-Ouest, Ouest, Sud-Est, and Sud (Figure 2). FIGURE 1. World Health Organization (WHO) operational framework for climate-resilient healthcare systems CLIMATE RESILIEN C E Leadership & Governance Health Workfo rc e H e a lt h F in a n c i n g C lim a te   & P r e p a r e d n e s s  & M a n a g e m e n t E m e r g e n c y H e a l t h I n f o r m e d C l i m a t e - P r o g r a m s D e trim ents E n v iro nm ental M a n a g em ent of o f H ealth Technologies& SustainableClimate Resilient & Infrastructure C lim a te   H e a lth  & R e se a rc h M o n it o r in g  & E a r ly  W a r n in g I n t e g r a t e d  R is k C a p a c i t y   & A d a p t a t i o n A s s e s s m e n t V u l n e r a b i l i t y , Service Delivery Financing Health Workforce Health Information Systems Essential Medical Products & Technologies Leadership & Governance BUILDING BLOCKS OF HEALTH SYSTEMS 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. 7 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) 8.5 a for the short term (2030s; 2020–2039) and the medium term (2050s; 2040–2059). a Information is provided for RCP4.5 in Annex B of this report. HAITI’S GEOGRAPHY 10. Haiti is  predominantly  situated on the western portion of the island of Hispaniola in the Caribbean Sea, with smaller islands surrounding the country, including Île-à- Vache, Gonâve, Grosse Caye, Les Cayemites, Navassa, and Tortuga Island. The mainland consists of mountains, plains, and valleys, which influence the climate conditions across the country. The mountainous northern region and the Northern Plain along the northern border with the Dominican Republic range in elevation from 600 to 1,100 meters (m). The central region consists of the Central Plateau that spans 85 kilometers (km) from the southeast to northwest, with a width of 30 km. To the southwest of the Central Plateau are the Montagnes Noires, with elevations of up to approximately 600 m. The southern region consists of the Plaine du Cul-de-Sac and the mountainous southern peninsula. The Plaine du Cul-de-Sac is a natural depression that is 12 km wide; it extends for 32 km from the border with the Dominican Republic to the coast of the Baie de Port-au-Prince. The mountains of the southern peninsula extend from the Massif de la Selle in the east to the Massif de la Hotte in the west. The range’s highest peak — the Morne de la Selle — is the highest point in Haiti, rising to an altitude of 2,715 m. The Massif de la Hotte varies in elevation from 1,270 m to 2,255 m. 8 | Climate and Health Vulnerability Assessment: Haiti Moreover, numerous rivers and streams traverse the plains and mountainous areas. The largest drainage system in the country is that of the Artibonite River. Rising from the foothills of the Massif du Nord as the Libón River, the river crosses the border into the Dominican Republic and then forms part of the border before re-entering Haiti as the Artibonite River. The 400-km Artibonite River is only one meter deep during the dry season, and it may even dry up completely in certain spots. During the wet season, it is more than three meters deep and subject to flooding. OBSERVED AND PROJECTED CLIMATE AND SEA-LEVEL RISES (SLRS) 11. Haiti has a hot and humid tropical climate that can be separated into six climate zones. The country is predominantly tropical savannah (55 percent), tropical rainforest (25 percent), and tropical monsoon (14 percent). These areas are characterized by high temperatures and precipitation rates. The wet season is long, particularly in the northern and southern regions of the island, with two pronounced peaks occurring between March and November. The remainder is arid (2.5 percent) — temperate without a dry season and with a hot summer (2.2 percent), or temperate with a dry winter and warm summer (1.7 percent). The north wind brings fog and drizzle, inter- rupting Haiti’s dry season from November to January. However, from February to May, the weather is very wet. Northeast trade winds bring rains during the wet season. Monthly 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). Northern and windward slopes in the mountainous regions receive up to three times more precipitation than the leeward side; annual precipitation in the mountains averages 1,200 millimeters (mm). In contrast, the annual precipitation in the lowlands is as low as 550 mm; the Plaine du Gonaïves and the eastern part of the Plaine du Cul-de-Sac are the driest regions in the country. FIGURE 3. Projected average monthly temperatures and precipitation levels in Haiti 120 mm 100 mm 80 mm 60 mm 40 mm 20 mm 0 mm DecJan Historical Ref. Period, 1986-20052020-2039 2040-2059 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Historical Ref. Period, 1986-20052020-2039 2040-2059 30 ˚C 29 ˚C 28 ˚C 27 ˚C 26 ˚C 25 ˚C 24 ˚C 23 ˚C 22 ˚C 21 ˚C 20 ˚C Source: World Bank Climate Change Knowledge Portal Climatology | 9 12. There is already evidence of the climate changing in Haiti: as Section III of this report will show, this situation is leading to significant human health impacts. Annual mean temperatures have steadily increased over the past half century. Since 1960, mean temperatures have risen by 0.45°C. Much of this warming has occurred between June and November. Temperatures across Haiti are fairly uniform: the variation in the subnational annual temperature is only approximately 2°C on average. The southwestern departments of Nippes, Grand’Anse, and Sud experience the warmest temperatures throughout the year, while the eastern departments of Centre and Sud-Est experience the coolest. 13. Precipitation is asymmetrical, due to the orientation of Haiti’s mountain chains and the rain-bearing northeast trade winds. On a national scale, variations in the average annual rainfall since the early 1900s have varied by less than 2 mm, with a rising trend recorded over time. Overall, Artibonite (1144 mm), Nord-Ouest (1198 mm), and Nord-Est (1220 mm) receive the least amount of average annual rainfall, while Sud (1955 mm) and Grand’Anse (1806 mm) receive the most. The heaviest rainfall has historically occurred in May for most departments, except for Grand’Anse, Nippes, and Sud-Est; they receive the most rainfall in October, with the Nord experiencing the heaviest rainfall in November. 14. The average national temperature will increase by 0.88°C in the 2020–2039 period and by 1.7°C in the 2040–2059 period, resulting in average temperatures of 26.35°C and 27.17°C, respectively. The month of September will have significant temperature increases for the two time periods, that is, 1.04°C and 1.81°C, respectively. Sub-nationally, the Nord-Est department will experience the highest increase (0.92°C by 2020–2039 and 1.76°C by 2040–2059). The maximum temperature is projected to reach an average of around 30°C (for both time periods), with the highest average maximum temperatures experienced in the Artibonite (31.27°C) and Nord (31.17°C) departments by 2020–2039. Moreover, the increases in the number of tropical nights (that is, where temperatures > 20°C), at the national level, are also expected to be 31.54 by 2020–2039 and 51.81 by 2040–2059. 15. Precipitation is expected to increase to 632.74 mm/year (+26.27 mm) by the 2020–2039 period, but it will decrease to 588.49 mm/year (–17.97 mm) by the 2040–2059 period. The month of October will experience the greatest increase of precipitation (+8.26 mm), while the greatest decrease (–7.7 mm) will take place in September during the 2020–2039 period. However, by the 2040–2059 period, there will be a decrease in precipitation of 18.95 mm in May. The department of Grand’Anse will experience the highest precipitation increase for the 2020–2039 period. However, all the departments will experience a decrease for the 2040–2059 period. 16. Over the past century, the rate of SLRs has roughly tripled in response to the increase in the global temperature of 0.8°C. SLRs pose a significant threat to islands across the globe, including Hispaniola. Since the 1950s, the mean SLR in the Caribbean region has been approximately 1.8 mm/year. Historic sea-level data recorded from Haiti are sparse: published tide tables from the National Oceanic and Atmospheric Administration (NOAA) for the Port-au-Prince date back to only 2019. The IPCC AR6 in 2021 2 reported that the mean global sea surface rose by 0.20 m between 1901 and 2018 — constituting an average SLR 10 | Climate and Health Vulnerability Assessment: Haiti FLOODS 19. Floods are the leading factor of vulnerability in Haiti and throughout history. Since 1991, the country has experienced 34 flood events (25 riverine floods, eight flash foods, and one coastal flood), 5 with the most populated cities — all nestled in valleys along the coast — most affected. Widespread deforestation in the upper reaches of these valleys, coupled with the lack of drainage infrastructure, has created an environment that is conducive to flooding. When it rains, the steep, often barren, hills surrounding them flush rainwater toward the urban areas. Riverine floods have impacted more than 502,910 people, leaving 3,024 lives lost and estimated damages of USD2,157,000, 6 since 1991. Almost all of Haiti’s 30 major watersheds are of concern, because of intense seasonal rainfall, storm surges in the coastal zones, and a deforested b and eroded landscape. Given b Haiti is one of the most deforested countries in the world, with forest cover estimated at just 1.5 percent. of 1.3 mm/year between 1901 and 1971 and 1.9 mm/year during the 1971–2006 period. 17. Available information suggests that SLR trends in the Caribbean have been broadly similar to global trends over this same period. 3 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 m (0.30–0.40 m) by the 2050s. 4 Considering the country’s topography, the Artibonite and Ouest departments have a great part of their land below 1 m above the sea level, where around 165,000 Haitians live (see Figure 4). CLIMATE-RELATED HAZARDS 18. Haiti is vulnerable to several extreme climate-related events that will be exacerbated by ongoing climate change. The most common are floods and hurricanes; but they also include landslides, droughts, and extreme temperatures. The impacts of these hazards are further compounded by anthropogenic causes, including deforesta- tion, coastal degradation, and urbanization. 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 Climatology | 11 the near-complete absence of embankments and levees, this cycle then intensifies the next round of flooding, leading to the destruction of crops, farmlands, and agricultural infrastruc- ture, as well as losses of livestock and human lives. On the other hand, coastal and flash floods account for approximately 85 percent of flooding cases. Flash floods have also resulted in adverse consequences since 1991 — 120,112 people affected, 98 lives lost, and damages estimated at USD1,439,000. 7 20. There is high confidence that storm surges will increase in tandem with the mean SLRs, thus leading to more coastal flood hazard 8 Haiti’s coastal flood hazard is classified as “medium,” that is, more than a 20 percent chance of potentially damaging coastal flood waves occurring in the next 10 years. 9 Its riverine and urban flood hazards are classified as “high,” which means that potentially damaging and life-threatening river floods and urban floods are expected to occur at least once in the next 10 years. Although the surface flood hazard in urban and rural areas is not included in this hazard classification, it may also be possible in the coming years. 21. Extreme precipitation magnitudes are projected to increase over the 2030s and 2050s. The average largest 1-day precipi- ta¬tion level will increase slightly to 43.15 mm (+1.76 mm) on an annual average by the 2030s (compared to the 1986–2005 period) and remain similar in the 2050s, at the national level. During the 2030s, the largest increase, with more risks of flooding, will be in October during the wet season (April to October). As for the 2050s, there will be a slight decrease in the average largest 1-day precipitation level (42.35 mm) (see Table 1). Sub-nationally, the greatest increases will be taking place in the Sud-Est and Ouest departments (+5.59 mm and +5.05 mm for the 2030s, along with +7.24 mm and +7.03 mm for the 2050s, respectively). On the other hand, projections of the 5-day cumulative precipitation, where areas can become saturated over several days, present a different flood risk. There will be an average increase of 9.68 mm for the 2030s nationally, especially during the rainy months, with the Grand’Anse department experiencing the greatest increase (+20.2 mm). In the case of the 2050s, there will be a slight decrease nationally (–2.33 mm), with Nord-Ouest expe- riencing the greatest decrease (–6.69 mm), while Grand’Anse will experience increases in its average 5-day cumulative rainfall (9.57 mm, anomaly). Lastly, while average largest 1-day precip- itation (in mm) will increase, the number of consecutive wet days will decrease for the 2030s and 2050s (–0.86 mm and –6.62, respectively). Also, the rainy days are going to be more scattered throughout the seasons. 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 12 | Climate and Health Vulnerability Assessment: Haiti HURRICANES 22. Haiti lies in the Caribbean hurricane corridor; thus, it is regularly affected by storm surges (see Figure 5). The country is mainly subject to tropical waves, which tend to be influenced by the intertropical convergence zone and carried from east to west by trade winds. These climate events can lead to tropical cyclogenesis and produce cyclonic systems characterized by excessive rainfall and strong winds, resulting in the formation of storms: convective storms, tropical storms, or hurricanes. 10 Haiti’s storm season goes from June through November, affecting mostly the West and South departments. Hurricanes constitute the second-most frequent disaster type, representing 40 percent of the country’s total disasters. 11 Hurricanes are also highly hazardous, with an approximately 20 percent chance of damaging wind speeds. 12 From 1991 to 2020, Haiti experienced a total of 35 storms — 31 hurricanes, three tropical storms, and one 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 convective storm. In 2021, Haiti was ranked third among the countries most affected by extreme weather events in the world. 13 23. In 2016, Hurricane Matthew made landfall in Haiti, and subsequently, became one of the most destructive hurricanes for Haiti. The country was subjected to days of intense precipitation, with the total exceeding 30 inches in some locales. 14 Due to its steep, deforested terrain, Haiti was vulnerable to floods and at risk of mudslides. 15 The intense precipitation resulted in extensive flooding, infrastruc- ture damage, crop losses, and significant mortality. 16,17 The hurricane also led to 600 deaths, with 2.1 million people impacted, 18 including over 50,000 internally displaced. 19 Sub-nationally, the hurricane caused consid- erable damage to the southern peninsula and the northwestern parts of the country. 20 In particular, the Grand’Anse and Sud — both of which were located in the southwestern tip of Hispaniola — were the most affected. Climatology | 13 24. Severe hurricanes are projected to increase in frequency and severity. Haiti’s geograph- ical location along the hurricane corridor will worsen the country’s vulnerability under climate change scenarios. By 2050, rainfall from hurricanes is expected to increase by 20–30 percent near the center, and by 10 percent in the outer circle of the hurricane (200 km or larger). Wind speeds from hurricanes will also increase by 2–11 percent. 21 Although the frequency of Atlantic storms is projected to decrease, the most severe hurricanes from the Atlantic that will make an incursion into the Caribbean will increase its frequency by 80 percent by the end of the century. 22 Cities such as Port-au-Prince and Gonaïves are 2–4 times more vulnerable to tropical storms than any other city in the country. 23 Increases in hurricane frequency and overall storm intensity will worsen flood and storm surge risks in the country. 24 LANDSLIDES 25. High deforestation rates, coupled with changing rainfall patterns, make landslides commonplace and particularly dangerous in steep sloping lands. 25 On many Caribbean islands, frequent heavy rains, the mountainous topography, and the volcanic geology combine to create high-hazard conditions for landslides (see Figure 6). On some slopes, landslides are common even when rainfall is only mild. The relationship between landslides and climate change is complex. While changes in rainfall and temperature may lead to more landslides, the increasing frequency of droughts, as projected in Haiti, may decrease the likelihood of these events. 26 In Haiti, landslides are common along all river valleys, where years of deforestation have left the upper reaches of the western basins bare. 26. Landslides are among the climate change- related hazards that Haiti experiences. Even though landslides are the least frequent disaster in the country (1 percent of the reported natural disaster distribution), 27 Haiti’s geographic location, which places it in the path of the 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. Taking into consideration the slope, the slope orientation, the water flows in the land, as well as hillside and geological factors, it is observed that most of Haiti has a moderate level of landslide susceptibility. At the subnational level, the highest levels of landslide susceptibility are in the zones where the mountains are located, especially in the southern and southeastern parts of Haiti, due 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 Léogâne — a city located in the western part of Port-au-Prince, the landslide risk is rated as “high” and “very high” (see Figure 6). In terms of potential damage, highways are highly susceptible to landslides, especially in the southern part of the country. For example, the highway that connects Port-au-Prince and Léogâne, along with the highway that starts in Port-au-Prince and continues to the eastern part of the country, are two of the riskiest roads in the country 29 (see Figure 6). 27. Projections about extreme precipitation events suggest that they would be the main trigger for future landslides. Increases in the average largest 1-day precipitation level for the 2030s indicate that landslides could occur concomitantly. Projections for the 2050s underline a decrease in rainfall, 14 | Climate and Health Vulnerability Assessment: Haiti which could reduce the risk of landslide. At the same time, the increased frequency and intensity of hurricanes could impact Haiti’s steep topography, resulting in more landslides. DROUGHTS 28. Haiti is susceptible to droughts due to rising temperatures related to climate change, deforestation, and limited water management infrastructures. Haiti is affected by the El Niño-Southern Oscillation — a climatic pattern that generates large-scale anomalies that increases surface temperatures in the Pacific Ocean. This climate phenomenon delays the start of the cyclone seasons, as well as increases the dry season. Departments in the North-West, Artibonite, North-East, and Central have experienced repeated droughts (see Figure 7). 30 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. From 1991 to 2020, the country went through five drought periods due to irregular and insufficient rainfall, resulting in crop failures, food shortages, and therefore, famine. 31 These events tend to appear during the dry season (generally from December to April), exacerbated by the influence of the El Niño- Southern Oscillation. The five drought events have affected 8,855,521 people. 32 29. As rainfall will decrease for the 2050s, droughts are expected to become more extreme. 33 The annual Standardized Precipi- tation Evapotranspiration Index (SPEI) drought index measures drought severity according to its intensity and duration. Negative SPEI values indicate a negative water balance, whereby the −2 value equates to “severe drought.” The annual SPEI drought index values for Haiti will be −0.42 for the 2030s and −0.68 for the Climatology | 15 2050s. 34 Although projections do not meet the −2 threshold, droughts would have an even greater impact, given Haiti’s vulnerabilities in its water management infrastructure and agriculture system. RISING TEMPERATURES 30. Rising temperatures in Haiti are going to be exacerbated by humidity. Whereas the previous discussion considered overall historic and projected temperature changes, this section will focus on temperature extremes defined as “temperatures ≥ 35°C,” using two classifications: (a) “very hot” days: ≥ 35°C; and (b) heat index days of ≥ 35°C. Notably, there are overlaps between these discussions, given how high current temperatures are across Haiti and the projections. FIGURE 7. Hazard climate drought zones Source: HaitiData.org. https://haitidata.org/layers/geonode_data:geonode:hti_hazardclimate_droughtzone_polygon_052010. 31. Although heatwaves in Haiti will remain an uncommon climatic event, humidity will increase the “feel-like” temperature. There are no reports of heatwaves or the number of “very hot” days to date. Moreover, projections for the 2020–2039 and 2040–2059 periods do not report any number of “very hot” days (Tmax > 35°C and > 40°C), under high-emissions scenario RCP8.5. 35 However, it is expected that this extreme temperature will increase in frequency from 2041 onwards. 36 Furthermore, the number of heat index days is expected to increase more drastically in the country. While Haiti will only experience an increase of 4.8 heat index days by the 2030s, however, the figure will accelerate to 31.42 by the 2050s nationally. It is projected that Grand’Anse will be the hottest department in the country, experiencing 25.25 heat index 16 | Climate and Health Vulnerability Assessment: Haiti days by the 2030s and 94.01 by the 2050s. Furthermore, departments — such as Ouest, Nord-Ouest, Sud-Est, and Sud — will go from registering approximately nine heat index days for the 2030s to roughly 60 days for the 2050s (see Table 2). WILDFIRES 32. High temperatures, coupled with the high rate of deforestation, increase the frequency and intensity of wildfires. In Haiti, the probability of weather conditions exacerbating a significant wildfire is greater than 50 percent. 37 The country has only 3 percent of forest cover remaining at the national level; combined with rising temperatures, this could enable the occurrences of wildfires. 38 The dependence of rural populations on charcoal, obtained from cutting trees, exposes them to wildfires and increases their vulnerability. In areas that have wildfire exposure, both duration and intensity have increased in the past years. 39 33. Wildfires in Haiti are likely to increase as a consequence of deforestation, prolonged dry spells, and the increase of high temperatures related to climate change. It is projected that these wildfires would increase in duration and severity. 40 However, there are no concrete estimations on how frequent and how intense they would become, or how they would impact human health. 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 Climatology | 17 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. 19 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: the proportion of communicable diseases is declining, while the proportion of noncom- municable diseases (NCDs) is increasing. This is important, since many communicable diseases and NCDs are climate-sensitive and will, therefore, interact with the overall climate-related burden of disease. Mental health and well-being are also important in the consideration of the climate-related burden of disease. Although the causes of mortality are poorly documented in Haiti, 41 the Haiti Health Plan uses the listing from the  Institute for Health Metrics and Evaluation (IHME) in setting out the 10 leading causes of death in the country. In 2019, they are ischemic heart disease (4.56 percent of the total disability adjusted life years [DALYS] c ); stroke (4.6 percent); lower respiratory tract infections (6.32 percent); human immunodeficiency virus 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 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 condition in a population. Source: Disability-adjusted life years (DALYS) (who.int). (HIV) / acquired immunodeficiency syndrome (AIDS) (5.3 percent); neonatal disorders (9.3 percent); diabetes mellitus (3.13 percent); diarrheal diseases (5.59 percent); birth defects (5.4 percent); acts of interpersonal violence (3.51 percent); and chronic renal failure (1.57 percent). 42,43 Of the 10 highest causes of death, HIV/AIDS showed the largest decrease, falling by 43.6 percent from 2009 to 2019, followed by diarrheal diseases (15.6 percent). These 2009–2019 changes in health outcomes suggest that the population is experiencing an epidemiological transition: mortality and morbidity caused by communicable, maternal, neonatal, and nutritional diseases (28.7 percent) and injuries (13 percent in 2016 and 9.3 percent in 2019) had declined, while NCDs had increased proportionally (57 percent in 2016 compared to 61.9 percent in 2019) (see Figure 8). 44 The disease burden attributed to NCDs (cardio- vascular diseases [CVDs], cancers, congenital defects, stroke, and diabetes) is caused by multiple contributing factors. However, the 20 | Climate and Health Vulnerability Assessment: Haiti link with climate change is clear. Increasing heat and drought conditions leads to the decreased yield and nutrient quality of crops, thus resulting in malnutrition. Poor air quality is caused by an increase in wildfires, as well as the continued burning of fossils and other household fuels. NCDs can also arise from a synergistic combination of multiple risk factors. In 2019, the three risk factors that account for the highest NCD burden in Haiti are (a) malnutrition, (b) air pollution, and (c) high blood pressure, respectively. All three have links to climate change, with pathophysiological links to CVDs (including hypertension) becoming better characterized. 45 The risk factors for the total burden of diseases (communicable diseases, NCDs, and injuries) are presented Figure 9, with the majority being impacted by climate change. 36. Exposure to health risks from climate change are inequitably distributed within and across populations. Factors that affect vulnerability to climate are often similar to those that affect health more broadly. 46 Further, climate may exacerbate existing health inequalities, affecting particularly vulnerable groups such as the elderly; women and young children; those living with pre-existing conditions and disabil- ities; as well as groups in poverty, including those occupying informal urban settlements, along with displaced and rural populations. 37. Haiti suffers from extreme weather events such as storms, floods, droughts, and wildfires. Due to its location within the hurricane basin, Haiti had been adversely affected by storms Jeanne (2004), Matthew (2016), and Hanna (2018) — all of which resulted in fatalities. 47 In the period between 1991 and 2020, 4,803,699 people were affected by storms, with 5,753 deaths recorded (see Table 3). Direct impacts, such as injuries due to climate-related events, represent 1.34 percent of the total DALYs in the country. 48 Tropical storms disproportionately impact those living in flood zones and coastal areas. 49 During FIGURE 9. Top 10 risks contributing to the total number of DALYs in 2019 and percent change, 2009–2019 — all ages combined Malnutrition Air pollution WaSH Unsafe sex High blood pressure High fasting plasma glucose Dietary risks High body-mass index Alcohol use Tobacco High LDL 2009 1 2 3 4 5 6 7 8 9 10 11 Malnutrition Air pollution High blood pressure High fasting plasma glucose WaSH Dietary risks Unsafe sex High body-mass index Alcohol use High LDL Tobacco % change, 2009-2019 -8.4% 0.7% 30.4% 33.9% -14.8% 27.6% -32.3% 41.6% 27.2% 30.1% 8.9% 2019 1 2 3 4 5 6 7 8 9 10 12 Metabolic risks Environmental/occupational risks Behavioral risks Source: IHME, http://www.healthdata.org/haiti. TABLE 3. Flood and storm events in Haiti from 1991 to 2020 EXTREME EVENTS SUBTYPE EVENTS COUNTTOTAL DEATHSTOTAL 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. FIGURE 8. Top 10 causes of total number of deaths in 2019 and percentage change, 2009–2019, all ages combined HIV/AIDS Ischemic heart disease Stroke Lower respiratory infect Neonatal disorders Diarrheal diseases Diabetes Congenital defects Interpersonal violence Chronic kidney disease 2009 1 2 3 4 5 6 7 8 9 10 Ischemic heart disease Stroke Lower respiratory infect HIV/AIDS Neonatal disorders Diabetes Diarrheal diseases Congenital defects Interpersonal violence Chronic kidney disease % change, 2009-2019 26.09% 20.9% -4.8% -43.6% 4.8% 22.6% -15.6% 5.8% 22.6% 30.3% 2019 1 2 3 4 5 6 7 8 9 10 Communicable, maternal, neonatal and nutritional diseases Non-communicable disease Injuries Source: Estimates generated by IHME and downloaded from http://www.healthdata.org/haiti. Climate-Related Health Risks | 21 health more broadly. 46 Further, climate may exacerbate existing health inequalities, affecting particularly vulnerable groups such as the elderly; women and young children; those living with pre-existing conditions and disabil- ities; as well as groups in poverty, including those occupying informal urban settlements, along with displaced and rural populations. 37. Haiti suffers from extreme weather events such as storms, floods, droughts, and wildfires. Due to its location within the hurricane basin, Haiti had been adversely affected by storms Jeanne (2004), Matthew (2016), and Hanna (2018) — all of which resulted in fatalities. 47 In the period between 1991 and 2020, 4,803,699 people were affected by storms, with 5,753 deaths recorded (see Table 3). Direct impacts, such as injuries due to climate-related events, represent 1.34 percent of the total DALYs in the country. 48 Tropical storms disproportionately impact those living in flood zones and coastal areas. 49 During FIGURE 9. Top 10 risks contributing to the total number of DALYs in 2019 and percent change, 2009–2019 — all ages combined Malnutrition Air pollution WaSH Unsafe sex High blood pressure High fasting plasma glucose Dietary risks High body-mass index Alcohol use Tobacco High LDL 2009 1 2 3 4 5 6 7 8 9 10 11 Malnutrition Air pollution High blood pressure High fasting plasma glucose WaSH Dietary risks Unsafe sex High body-mass index Alcohol use High LDL Tobacco % change, 2009-2019 -8.4% 0.7% 30.4% 33.9% -14.8% 27.6% -32.3% 41.6% 27.2% 30.1% 8.9% 2019 1 2 3 4 5 6 7 8 9 10 12 Metabolic risks Environmental/occupational risks Behavioral risks Source: IHME, http://www.healthdata.org/haiti. TABLE 3. Flood and storm events in Haiti from 1991 to 2020 EXTREME EVENTS SUBTYPE EVENTS COUNTTOTAL DEATHSTOTAL 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 most frequent natural hazard in Haiti (47.58 percent). 50 For example, in 2004, intense precipitation resulted in two major floods with more than 2,700 fatalities, affecting more than 300,000 persons and severely damaging hospitals and health centers 51 (see Table 3). The capital city of Port-au-Prince is particularly vulnerable to flooding, with a large portion of its inhabitants residing on flood plains in poorly constructed housing. 52 22 | Climate and Health Vulnerability Assessment: Haiti 38. Extreme weather events, such as storm surges, floods, and wildfires, are expected to become more frequent and intense. They can act as a force multiplier: for example, flooding causes soil erosion, which leads to decreased crop productivity and livestock, and, in turn, malnutrition. This is just one example of a synergistic interaction causing climate-related health risks. 53 39. Haiti’s CHVA assesses six climate-related health risk categories. They include nutrition risks, waterborne and water-related diseases, vector-borne diseases (VBDs), heat-related morbidity and mortality, air quality health risks, as well as mental health and well-being. Each category is assessed, in terms of current and future risks, with considerations for both distinctive national and subnational features, where possible. It is important to note that these categories represent only the most pressing health risks to the population in Haiti. NUTRITION RISKS 40. Weather and climate are the foundational drivers of healthy and sustainable diets. The mechanisms by which climate change affects nutrition via the food system are profound; they include acute and chronic effects on agricultural production, storage, processing, distribution, and consumption (see Figure 10). Nutritionally secure and stable diets not only depend on agricultural production, but also on the complex interactions of demand, economics, legislation, conflict, food waste, nutrient losses, food safety, and access. 54 Climate variability is already contributing to increases in global hunger and malnutrition. 55 While a comprehensive analysis of the climate change’s impact on the food system is beyond the scope of this assessment, this CHVA examines climate and nutrition linkages through a food security lens in Haiti, as it relates to the weather and climate impacts on agricultural productivity. Agricultural productivity — a key determinant of food avail- ability — is affected by weather and climate in a multitude of ways: such events ranging from short-term shocks (for example, natural disasters) to longer term changes in agroeco- logical conditions can drastically reduce yields or redefine the spatio-temporal patterns of crop suitability. 41. The level of chronic food insecurity in Haiti is among the highest in the world. Nearly half of the population (44 percent: 4.3 million people) face acute food insecurity, with the prevalence of undernourishment among 46.8 percent of the population for the 2018–2020 period. 56 The main causes of food insecurity and malnutrition in Haiti include low agricul- tural productivity, economic decline, limited access to clean water and sanitation, poverty, and political instability. 57 Agricultural productivity has languished in response to (a) recurrent natural disasters unrelated to climate (for example, earthquakes), (b) extreme weather events (for example, storms, flooding, landslides, and droughts), (c) high levels of environmental degradation, (d) the heavy reliance on rainfed agriculture, and (e) limited access to information and modern farm technologies. 58 Agriculture employs half of Haiti’s total employment, with most farmers operating small (< 2 hectares [ha]) rainfed subsistence farms 59 that are highly vulnerable to climate stresses and shocks, such as the El Niño / La Niña phenomenon, which have increased the duration of dry spells. 60 42. As of 2018, 21.9 percent of children under five years old in Haiti were estimated to be Climate-Related Health Risks | 23 stunted and 3.7 percent wasted, with the child mortality rate recorded at 8.3 percent. Sub-nationally, the Centre department had the highest prevalence of stunting (30.1 percent), while Artibonite had the highest child wasting rate (4.3 percent) and the Ouest department had the highest child mortality rate (11.2 percent) (see Table 4). According to the Integrated Food Security Phase Classification (IPC) phases of severity for acute food insecurity, 14 percent of the country’s population was classified under “emergency” (IPC Phase 4 d ) as of the reporting period from September 2021–February 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 emergency livelihood strategies and liquidating assets. [[I had to “Accept Changes” here, because Word seems to be buggy with footnotes]] FIGURE 10. Stages of the food system that drive healthy and sustainable diets Climate Change Land Use Water Use Waste Extreme Weather Legislation & Policies Post-harvest Loss Mycotoxins Nutrient Losses Waste Nutrient Losses Fortification Waste Legislation Demand Trade Politics Economics Nutrient Losses Waste Culture Afordable Accessible Preferences Nutrient Losses Waste Agriculture Production Processing Distribution Consumption Healthy &  Sustainable Diet Unhealthy & Unsustainable Diet Storage Source: Macdiarmid and Whybrow 2019. 2022. The populations were mostly living in areas in the Centre, Nord-Ouest, and Sud-Ouest departments; while 33 percent of the population (approximately 2,995,664), classified under “crisis” (IPC phase 3 e ), was distributed throughout the national territory (see Figure 11). 43. Haitians’ diets are characterized by poor quality and limited diversity. Their diet is based on rice, maize, wheat, and sorghum, which is lacking in terms of foods rich in proteins such as fish, meat, dairy, or eggs. 61 Furthermore, rice consumption is dependent on imports, which have increased since the 1980s. 62 Nutritional concerns are linked to e IPC Phase 3: Households either have food consumption gaps, reflected by high or above-usual acute malnutrition, or are marginally able to meet minimum food needs, but only by depleting essential livelihood assets or through crisis-coping strategies. 24 | Climate and Health Vulnerability Assessment: Haiti periods of the agricultural year when food is less available, namely April–June. 63 44. The exodus of the rural population to cities and abroad, and a lack of agricul- tural development, have also reduced food crops. The country’s food imports — valued at USD1.05 billion by 2020 — rose by 21.2 percent from 2019. In particular, 80 percent of rice — an important food for Haitians — is imported. Other products, such as wheat, are also reliant on imports, as domestic production does not meet demand. 64 The country’s dependency on food imports increases the vulnerability of its food systems. If supply countries are dealing with climate shock impacts in their crop production, they may not be able or willing to cater to Haiti’s import needs. Moreover, regarding food afford- ability, the continued depreciation of Haitian currency, exchange rates, and the increased cost of public transportation due to fuel prices have also increased the vulnerability of poor Haitians primarily, as they cannot buy food for their households. 65 45. Droughts, soil erosion, reduced water supply, and increased crop damage have worsened food insecurity. Increased extreme rainfall triggers soil erosion and reduces soil fertility, aggravated by prolonged drought periods. Soil erosion is also worsened by deforesta- tion rates in Haiti. Moreover, as droughts are expected to increase their duration and 92 percent of Haiti’s agriculture is rainfed, this will lead to a reduction of crop yield. 66 46. Considering the projected decline of rainfall previously reported and an increase in the drought index, this would have important consequences on the replenishment of soil moisture and the availability of water 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. Climate-Related Health Risks | 25 periods of the agricultural year when food is less available, namely April–June. 63 44. The exodus of the rural population to cities and abroad, and a lack of agricul- tural development, have also reduced food crops. The country’s food imports — valued at USD1.05 billion by 2020 — rose by 21.2 percent from 2019. In particular, 80 percent of rice — an important food for Haitians — is imported. Other products, such as wheat, are also reliant on imports, as domestic production does not meet demand. 64 The country’s dependency on food imports increases the vulnerability of its food systems. If supply countries are dealing with climate shock impacts in their crop production, they may not be able or willing to cater to Haiti’s import needs. Moreover, regarding food afford- ability, the continued depreciation of Haitian currency, exchange rates, and the increased cost of public transportation due to fuel prices have also increased the vulnerability of poor Haitians primarily, as they cannot buy food for their households. 65 45. Droughts, soil erosion, reduced water supply, and increased crop damage have worsened food insecurity. Increased extreme rainfall triggers soil erosion and reduces soil fertility, aggravated by prolonged drought periods. Soil erosion is also worsened by deforesta- tion rates in Haiti. Moreover, as droughts are expected to increase their duration and 92 percent of Haiti’s agriculture is rainfed, this will lead to a reduction of crop yield. 66 46. Considering the projected decline of rainfall previously reported and an increase in the drought index, this would have important consequences on the replenishment of soil moisture and the availability of water 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. resources and, therefore, on food security for both the 2030s and the 2050s. The scarcity of water — pivotal for agriculture and livestock —is classified as a medium-level hazard in Haiti. 67 This means that there is up to a 20 percent chance that a drought still occurs in the coming 10 years. Although rice is not projected to be as impacted by climate change as other crops, 68 water scarcity and water management in Haiti could increase food insecurity in the country. Although the drought index is projected to be mild, the increased intensity of hurricanes and the overall decrease in precipitation, coupled with an inadequate water management infrastructure, the lack of development in the agricultural sector, and a dependency on food imports, will increase the country’s vulnerability to food insecurity. WATERBORNE AND WATER-RELATED DISEASES 47. Waterborne and water-related risks are prevalent in Haiti. This is a consequence of intense precipitation and drought conditions, coupled with inadequate water and sanitation systems. Climate change can cause the re-emergence of waterborne infectious diseases, as well as increase the persistence and virulence of pathogens. 69 The tropical climate creates sudden, extreme weather events, such as hurricanes and intense precipitation, with flash flooding in urban areas, resulting in the mixing of sewage with fresh water and consequent waterborne disease (WBD) outbreaks. The construction of homes on hill tops and deforestation results in landslides, as well as the buildup of waste in drains and culverts, causing multiplier risks and outcome challenges. 26 | Climate and Health Vulnerability Assessment: Haiti 48. The population of Haiti is already vulnerable to waterborne and water-related diseases which may increase in response to the changing climate. Haiti has the highest mortality rate for enteric diseases for all ages — both male and female (33.11 per 100,000 inhabitants) in the Latin America and the Caribbean (LAC) region and the western hemisphere 70 (see Figure 12). This is related to its poor water, sanitation, and hygiene (WaSH) infrastructure. Sixteen percent of the deaths of children under the age of five is directly related to WBDs 71 such as cholera. 72 Water and sanitation systems in Haiti are already fragile, leaving the population vulnerable to the transmission of diseases such as cholera, diarrhea, dysentery, hepatitis A, and typhoid. In low-income countries, changes in climate are expected to influence diarrhea rates; 73 however, the extent will vary depending on climate change scenarios and local factors. 74 49. Extreme climate-related events in Haiti, such as hurricanes and floods, have increased the incidence of WBDs. 75 Hurricane Matthew in October 2016 resulted in increases in WBDs, and notably, a significant outbreak of cholera, 76 introduced by responders from overseas. Cholera became endemic from 2010 to 2018, resulting in approximately 819,000 reported cases and 9,786 deaths. 77 Contamination of the Meye tributary system of the Artibonite River, the poor sanitation services and the poor treatment of drinking water accelerated the epidemic, which then made the disease endemic. 78 The graph below shows the spike in enteric infections at the time of the earthquake, with Haiti having the highest rates in the LAC region (Figure 12). No cholera cases had been reported since 2019, and Haiti was declared free of cholera in February 2022. 79 Communities on the coast my also be exposed to increased risk of toxic algal blooms under a warming climate. These blooms are formed by dinoflagellates, which can result in paralytic and neurotoxic shellfish poisoning, as well as ciguatera fish poisoning (CFP). The LAC region experienced 7,800 incidents of human intoxication between 1970 and 2007, including 119 fatalities mainly associated with paralytic shellfish poisoning (PSP) along the Atlantic and Pacific coasts, and CFP in the Caribbean zone. 80 Shellfish FIGURE 12. Enteric infections deaths per 100,000 in the LAC region 150 100 50 0 199019921994199619982000200220042006200820102012201420162018 Haiti Source: IHME. Climate-Related Health Risks | 27 and fish are important sources of protein in Haiti, particularly for coastal communities, thus making their contamination particularly devastating. These algal blooms can flourish in both coastal waters and inland fresh water sources, with growth stimulated by increasing temperatures. 81 The Great South coastal areas are most affected, with significant concern reported in the communities of St Jean du Sud, Les Cayes, St Louis du Sud, Côtes de Fer, Jacmel, Cayes Jacmel, and Marigot. 82 50. Climate change has resulted in sargassum inundation on beaches. Concerns in the region began in 2011, with the Ministère de L’Envi- ronnement (MDE) in Haiti drawing attention to the issue since 2015. 83 When sargassum decomposes, it produces hydrogen sulfide — a gas that causes adverse cardiovascular and respiratory impacts, irritation to the upper airways and eyes, as well as neurobehavioral effects and symptoms. 84 Additional concerns include carcinogenic properties and the health risks associated with the accumulation of heavy metals, particularly arsenic and cadmium, in sargassum, although the evidence has yet to be fully established. 85 VECTOR-BORNE DISEASES (VBDS) 51. Weather and climate are critical drivers of spatio-temporal VBD distribution and trans- mission dynamics. f At large scales, climate variability causes vector and host ranges to expand or contract, shifting the disease distri- bution and seasonality, and / or facilitating emergence or re-emergence of VBDs. 86 At local scales, vector abundance is a product of f The main endemic insect vectors of infectious diseases in Haiti are as follows: Ae. mosquitoes — vectors of dengue, chikungunya, Zika, and yellow fever; An. albimanus — the primary mosquito carrying the malaria parasites; Culex mosquitoes carrying the West Nile virus fever and lymphatic filariasis; and Phlebotomas sandfly transmitting Leishmaniasis. microclimates, the availability of larval sites, the shade for resting, the sources of blood meals and nectar, and predator density. 87 This assessment focuses on mosquito-borne VBDs, including malaria, dengue, chikungunya, and Zika, due to their significant impact on Haiti. Other known mosquito-borne VBDs in Haiti include yellow fever and the West Nile virus fever. Likewise, other VBDs present in Haiti are lymphatic filariasis and leishmaniasis. Spatial models were constructed to demonstrate the plausible spatial distributions of the Anopheles (An.) vectors of malaria and the Aedes (Ae.) vectors of dengue, chikungunya, and Zika to assess the risk propensity of these diseases. The results of these analyses should be taken as conservative estimates of the areas of Haiti that exhibit suitable conditions for vector breeding and suitable conditions for vector breeding where humans are present (that is, populated areas). The time frames under consideration are the historical reference period (1986–2005), the 2030s, and 2050s to match the data presented in Section II of this assessment. For further information on modeling methodology and inputs, see Annex A. MALARIA 52. Despite nearly achieving the elimination of malaria in the 1960s, 88 malaria remains an ongoing public health problem in Haiti, especially among the populations of Ouest, Grand’Anse, Artibonite, and Sud (Table 5). After a surge in cases in the 1970s, more recent efforts have resulted in the number of malaria cases falling from 30,000 cases in 2012 to 10,000 in 2019. 89 In 2019, malaria contributed to 0.46 percent of total deaths, with mortality reported as ranging from 5–19 28 | Climate and Health Vulnerability Assessment: Haiti per annum over the 2010–2020 period, 90 and constituting 0.45 percent of the total DALYs. 91 The incidence rate is now approximately 1,278 per 100,000, with the highest rates of transmis- sion occurring after the rainy seasons of March to May and October to November, 92 in the rural Grand’Anse department, 93 although other sources suggest that the Ouest department has 49 percent of the cases. 94 The primary vectors of malaria in Haiti are An. albimanus and An. pseudopunctipennis. 95 Female An. albimanus and An. pseudopuncti- pennis mosquitos will feed on both human and animals, but with some inconsistent biting and resting behaviors demonstrated across their range; they utilize both indoor and outdoor resting sites. Notably, An. pseudopunctipennis mosquitoes have broad thermal tolerance, ranging from 12°C–36°C, which has enabled the survival of the species across most of the Americas and throughout Haiti. 53. The malaria transmission risk in Haiti will largely remain unchanged through the mid-century, but will decline within the Sud-Est, Ouest, and Nippes departments. Throughout much of the country, projected temperature increases will not exceed the thermal tolerance of malaria vectors. Likewise, the minimum temperatures are already high enough to support the malaria species survival. Range expansion is not projected to occur according to this analysis; however, the overall suitable area will decline by 2.9 percent (35 square kilometers [km²]), 2.7 percent (134 km²), and 6.2 percent (126 km²), in Nippes, Ouest, and Sud-Est, respectively. These changes will likely place nearly 100,000 fewer people at risk of malaria transmission. Changes to the geography of the malaria risk in Haiti through the mid-century are most likely to be attributable to human modifications of the landscape (that is, land use and land cover [LULC] change) that facilitate vector breeding and population increases, along with the adoption of malaria prevention, treatment, and control strategies. Notably, the opportunity to eliminate malaria on Hispaniola Island (comprising both Haiti and the Dominican 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) TABLE 6. Current and projected suitable areas for malaria vectors, by department DEPT, PROPORTION OF REGION BY AREA SUITABLE FOR MALARIA VECTORS VULNERABLE POPULATION POPULATED, SUITABLE OVERALL SUITABILITY ABSOLUTE VALUES DELTA (REF. PERIOD) DEPT. REF. PERIOD (%) 2030s (%) 2050s (%) REF. PERIOD (%) 2030s (%) 2050s (%) REF. PERIOD2030s 2050S 2030s2050s Artibonite 32.432.4 32.4 96.8 96.896.8 930,337 930,337 930,337 0 0 Centre 18.618.6 18.6 98.9 98.998.9 486,842 486,842 486,842 0 0 Grand’Anse 16.116.1 16.1 68.4 68.468.4 295,563 295,563 295,563 0 0 Nippes 39.839.839.5 85.5 85.582.6 243,396 243,396 237,277 0 6,119 Nord 38.138.1 38.1 84.6 84.684.6 456,287 456,287 456,287 0 0 Nord-Est 36.736.7036.7 97.1 97.197.1 135,350 135,350 135,350 0 0 Nord-Ouest 16.716.7 16.7 92.7 92.792.7 412,288 412,288 412,288 0 0 Ouest 39.539.538.0 88.3 88.385.61,064,6561,064,6561,027,1430 37,513 Sud 44.544.5 44.5 91.3 91.391.3556,056 556,056 556,056 0 0 Sud-Est 32.130.729.9 95.492.089.2 443,699 415,885 394,10127,81449,598 TOTAL5,024,4744,996,6604,931,24427,81493,230 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 Sud-Est, Ouest, and Nippes departments. Throughout much of the country, projected temperature increases will not exceed the thermal tolerance of malaria vectors. Likewise, the minimum temperatures are already high enough to support the malaria species survival. Range expansion is not projected to occur according to this analysis; however, the overall suitable area will decline by 2.9 percent (35 square kilometers [km²]), 2.7 percent (134 km²), and 6.2 percent (126 km²), in Nippes, Ouest, and Sud-Est, respectively. These changes will likely place nearly 100,000 fewer people at risk of malaria transmission. Changes to the geography of the malaria risk in Haiti through the mid-century are most likely to be attributable to human modifications of the landscape (that is, land use and land cover [LULC] change) that facilitate vector breeding and population increases, along with the adoption of malaria prevention, treatment, and control strategies. Notably, the opportunity to eliminate malaria on Hispaniola Island (comprising both Haiti and the Dominican 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) TABLE 6. Current and projected suitable areas for malaria vectors, by department DEPT, PROPORTION OF REGION BY AREA SUITABLE FOR MALARIA VECTORS VULNERABLE POPULATION POPULATED, SUITABLE OVERALL SUITABILITY ABSOLUTE VALUES DELTA (REF. PERIOD) DEPT. REF. PERIOD (%) 2030s (%) 2050s (%) REF. PERIOD (%) 2030s (%) 2050s (%) REF. PERIOD2030s 2050S 2030s2050s Artibonite 32.432.4 32.4 96.8 96.896.8 930,337 930,337 930,337 0 0 Centre 18.618.6 18.6 98.9 98.998.9 486,842 486,842 486,842 0 0 Grand’Anse 16.116.1 16.1 68.468.468.4 295,563 295,563 295,563 0 0 Nippes 39.839.839.5 85.5 85.582.6 243,396 243,396 237,277 0 6,119 Nord 38.138.1 38.1 84.6 84.684.6 456,287 456,287 456,287 0 0 Nord-Est 36.736.7036.7 97.1 97.197.1 135,350 135,350 135,350 0 0 Nord-Ouest 16.716.7 16.7 92.7 92.792.7 412,288 412,288 412,288 0 0 Ouest 39.539.538.0 88.3 88.385.61,064,6561,064,6561,027,1430 37,513 Sud 44.544.5 44.5 91.3 91.391.3556,056 556,056 556,056 0 0 Sud-Est 32.130.729.9 95.492.089.2 443,699 415,885 394,10127,81449,598 TOTAL5,024,4744,996,6604,931,24427,81493,230 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. 30 | Climate and Health Vulnerability Assessment: Haiti DENGUE 54. Despite an absence of routine systematic surveillance data, dengue is considered to be endemic in Haiti, as it is in the Dominican Republic. 97 A study from 2011 demonstrated the high prevalence of antibodies against dengue virus in all age groups — with 65 percent of three-year-olds already having antibodies from exposure to the virus, as well as evidence of hyperendemic trans- mission in the western and southeastern departments of Haiti. 98 Dengue is transmitted by the bite of infected Ae. aegypti and, to a lesser extent, Ae. albopictus mosquitoes. Over the 2004–2014 period, the number of cases of dengue and the severity of dengue virus infections have increased in the Americas, including the Caribbean. 55. Over seven million people in Haiti are vulnerable to dengue transmission, with the populations of Ouest and Artibonite at highest risk. The suitability for dengue vectors in Haiti has a distinctly spatial character, with suitable areas largely located within population centers across the country. Ae. Mosquitoes, which transmit dengue, prefer biting humans over animals; they are commonly found in urban and peri-urban environments. Notably, projected increases in maximum tempera- tures through the mid-century will not be high enough to reduce the overall suitable area for dengue mosquito-vector species. Likewise, minimum temperatures are already high enough throughout the county to enable vector development and survival. Very likely, the geography of dengue vectors throughout the country will be determined by changes in LULC driven by population expansion. Haiti’s population is projected to reach by 2050 (Figure 14), which will create opportunities for vector-breeding sites, as new commercial and residential areas are developed in the absence of coordinated vector control measures. Importantly, while the findings of this analysis are meant to support dengue control measures, results TABLE 7. Vulnerable populations and areas suitable for malaria vectors DEPARTMENT PROPORTION OF REGION BY AREA SUITABLE FOR MALARIA VECTORS VULNERABLE POPULATION 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. Climate-Related Health Risks | 31 may be extrapolated to assist in curtailing chikungunya and Zika risks as well, given that these diseases are vectored by the same Ae. mosquito species. 56. Chikungunya is caused by an arbovirus: it is transmitted to humans through the bite of a mosquito of the genus, Aedes (Ae.), mainly Ae. aegypti. Cases of chikungunya were first diagnosed in Haiti in 2014, when the Ministère de la Santé Publique et la Population (MSPP or the Ministry of Public Health and Population) reported a cumulative total of 39,343 cases between May 31 and June 16, 2014 in the 10 departments; the infection rate for Ouest was 67 percent. 99 Today, the incidence rate is reported to be 627 per 100,000 population. 100 57. Zika is caused by the flavivirus, which is transmitted through the bite of an infected 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. Ae. genus mosquito. The disease was only identified in 2015, originally in Brazil, due to the unusually high incidence of congenital microcephaly, which can result in adverse fetal outcomes and neurological conditions in adults. 101 58. The Zika disease spread through the Americas to the Caribbean including Haiti, and was declared a public health emergency of international concern by WHO in February 2016. 102 During the emergence period of the disease — October 12, 2015 to Sept 10, 2016, MSPP reported 3,036 suspected cases of infection in the general population, with 22 suspected cases of the Zika virus disease in pregnant women, 13 suspected cases of the Guillain-Barré syndrome (GBS), and 29 suspected cases of Zika virus-associ- ated congenital microcephaly. The National 32 | Climate and Health Vulnerability Assessment: Haiti Laboratory tested 294 specimens and found that 6.5 percent were positive. 103 It is reported that the surveillance program in Haiti needs to be strengthened to better monitor the evolution of Zika disease in Haiti. 104 59. Despite the strong correlation between VBD vectors and climate factors, climate is merely one determinant in the VBD transmission risk. The future risk of these diseases will depend on the changing climate conditions that define vector suitability, as well as envi- ronmental, social, and economic conditions. HEAT-RELATED MORBIDITY AND MORTALITY 60. The health risks associated with heat include acute mortality; heat-related morbidity such as heat rash, cramps, exhaustion, dehydration; and the acute exacerbation of pre-existing conditions such as respiratory and CVDs; 105 individuals on medications are at further risk of detrimental interactions. There are no specific data on the impacts of heat on health in Haiti, nor are there clear projections. However, the impact of humidity, which can be high in Haiti, exacerbates the impacts of heat on health and well-being; this measure and projection are captured by the “heat index” reported in the climatology section of this assessment. 61. Heat-related morbidity and mortality creates pressure on the healthcare system. 106 Heat strokes, which can be described as the core body temperature exceeding 40°C (104°F) and leading to a central nervous system dysfunction, is perhaps the most dangerous heat-related illness, as it can result in severe morbidity and mortality. 107 When high tempera- tures interact with air quality, the levels of ozone, pollutants, and aeroallergens are affected, which can, in turn, result in acute exacerbations of chronic respiratory and cardiovascular conditions. 108 Further, although there is no evidence of heatwaves as a major hazard for health in Haiti, the incremental increases in mean tempera- tures and the number of heat index days and tropical nights, along with the increase in the frequency of heatwaves predicted, during the 2041–2060 period under high-emissions scenario RCP8.5, 109 combine to present an 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 risk of mortality due to high temperatures, g with DALYs at 108.11 per 100,000. 110 62. Extreme heat also has an impact on mental health and well-being. 111,112 High temperatures can aggravate mental health symptoms, as well as increase the risks of suicide 113 and conflicts. 114 More generally, research has shown that hot nights are associated with insomnia, 115 with consequences including susceptibility to diseases and chronic illnesses, 116,117 as well as adverse impacts on psychological and cognitive functioning. 118,119,120 63. Heat is an occupational health risk. There is a lack of reporting on heat-related injuries, illnesses, and deaths amongst occupations in Haiti. Nonetheless, studies from other countries indicate that workers in agriculture and construction are at a particularly high risk of occupational heat stress. 121 Climate-based indices can be used to quantify workdays lost to extreme heat, reflecting recommended heat strain thresholds. 122 Furthermore, studies on g “High” temperature is defined as a daily mean temperature that is warmer than the theoretical minimum risk exposure level value (TMREL) — the temperature with the minimum level of mortality for all included 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 Metrics and Evaluation (healthdata.org). Climate-Related Health Risks | 33 age-specific heat-related mortality indicate that heat-related mortality is high in adults in Haiti, compared with temperate or middle- income countries where heat-related mortality is only apparent in the older age groups (over 65 years old). AIR QUALITY HEALTH RISKS 64. Global mortality, driven by the fossil fuel components of PM2.5, is estimated at 10.2 million per year. 123 Smoke from wildfires, dust storms, and other air pollutants can affect health acutely, as well as contribute to the development of severe chronic health conditions due to fine particulate matter (PM2.5) and other toxins. Health impacts include the increased risk of respiratory infections, lung cancer, COPDs, exacerbations of asthma, CVDs, and the advancement of dementia. Reducing fossil fuel usage has the clear co-benefits of producing both desired climate and health outcomes. 124 Those who are particularly vulnerable to particulate air pollutants include those with known asthma, chronic obstructive pulmonary diseases (COPDs), children. Ground- level ozone affects lung functioning, impacting individuals with asthma in particular, and can lead to premature mortality. In densely built-up population areas, rising temperatures can result in “smog-heat island” effects; smog also forms where air stagnates, for example, in low-lying regions. Other contributors to poor air quality in Haiti include power generation, diesel generators, and waste burning — all of which contribute as a positive feedback mechanism to climate-related health impacts. 65. The kinetics of the changing climate also influences atmospheric dust pollution. Changes in wind patterns and strengths lead to increased PM2.5 such as, with desertifica- tion in some regions also exacerbating dust formation, while heat and droughts increase wildfire risks — all of which can result in severe health impacts through inhalation. Specifically, changes in wind patterns and increased desertification increase the long-range transport of air pollutants. Under certain atmospheric circulation conditions, the transport of pollutants — including aerosols, carbon monoxide, ozone, desert dust, mold spores, and pesticides — may occur over large distances and over timescales typically of 4–6 days, leading to adverse health impacts. 125 Available data indicates that Port-au-Prince and Cap-Haïtien are areas that are the most affected. 66. In Haiti, mortality from particulate air pollution was responsible for about 14.05 percent of all-cause mortality. 126 The combined health impact of household exposures to particulate air pollution from the inadequate combustion of solid cooking fuels, plus general ambient pollution, was about 5,840 DALYS per 100,000 annually during the 2009–2019 period. 127 Over the 2009–2019 period, air pollution was the second-highest contributor to DALYS in Haiti across all age groups, second only to malnu- trition. 128 Haiti’s annual mean concentrations are 19.0 micrograms per cubic meter (µg/ m3) h for PM2.5 and 76.44 µg/m 3 (39 parts per billion [ppb] i ) for ozone in 2019. 129 These values exceed the WHO recommended maximum of 5 µg/m 3 for PM2.5 and 60 µg/m 3 for ozone. Since 1990, the population-weighted concentrations of both ambient particulate matter and ambient ozone pollution in Haiti have fluctuated, even as the proportion of population using solid fuels (HAP) has fallen continuously since 2010. Despite this fall, air h µg/m 3 = micrograms per cubic meter, that is, one-millionth of a gram. i Ppb = parts per billion; for ozone, 1ppb = 1.96 µg/m 3 (WHO guidance at 25°C) — Microsoft Word - Conversion Factors Between ppb and.doc (defra.gov.uk). 34 | Climate and Health Vulnerability Assessment: Haiti quality in Haiti is considered to be “moderately unsafe,” according to the 2021 WHO’s air quality guidelines. 130 67. Air pollution affects pregnant women, the developing fetus, or both, in ways analogous to tobacco smoking — a well-known risk factor for low birth weight and preterm birth. Babies —born too small or too early — are more susceptible to health problems such as lower respiratory infections, diarrheal diseases, brain damage and inflammation, blood disorders, and jaundice. Low birth weight and preterm birth are the leading risk factors for death in the first month of life. Other vulnerable groups are children under 5 years old and the elderly, due to damage and inflammation in the respiratory and cardiovascular systems in particular. 68. Improvements to air quality will result in co-benefits for the climate and the health of populations. While those who have been exposed to air pollutants over long periods may already have chronic damage to lungs and arteries that may have evolved into cancers, heart disease, strokes, dementia, and COPDs in the years ahead, reducing or stopping exposure can halt further deteri- oration and resulting early mortality. At the same time, the improvement of air quality can also reduce triggers for acute-on-chronic 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 and ambient air pollution, age-stan- dardized (per 100,000 population) 184.3 48.33 Haiti is the highest in the region. 92.43 Haiti is ranked 23rd in the world. Source: USAID. 220 morbidity, such as the exacerbations of COPDs and asthma attacks. MENTAL HEALTH AND WELL-BEING 69. The association between climate change-re- lated events and mental health can be direct or indirect, short-term and long-term. Acute events (such as floods) in the short term can precipitate a psychopathological pattern similar to experiencing traumatic stress, whereas exposure to extreme or prolonged weather-re- lated impacts may result in delayed mental impacts, such as symptoms of post-traumatic stress in the future, or psychological impacts on younger generations. For example, mental health impacts in children can be manifested as behavioral disorders. Nonetheless, the impacts of climate change and extreme climate events on mental health and well-being are mediated by individual and community resilience. The 2019 mental disorders epidemiology for Haiti records 1,660 DALYs per 100,000 population. 131 However, given that the diagnostic capacity in the country is minimal, the data may not reflect the actuality. To be fair, research on the effects of mental health outcomes related to climate change lags behind the research related to physical health at the global level. Climate-Related Health Risks | 35 70. To assess mental health in the context of climate change, the full spectrum from mental “illness” to psychological and social well-being, or “psychosocial health,” is considered. This allows for the incorpora- tion of the considerations of well-being and resilience. 132 Adopting such an approach is particularly relevant in Haiti, where there is background strain on the resilience of the population, as well as limited opportunities for psychological or psychiatric assessments and diagnoses to inform an analysis. The concept of mental health and well-being can thus be framed as a spectrum of “psychosocial health.” It embodies the diverse psychological and social strains of climate change impacts such as housing, water, and income insecurities, as well as living in physically uncomfortable drought or humid conditions. 71. Extreme weather events can result in direct trauma, anxiety, and depression through personal injury, the death and injury of a close relative, damage or loss of property, as well as disruptions to livelihoods. Intense negative emotions, such as terror, anger, and shock, are recognized acute responses to natural disasters. These extreme events can also result in long-lasting psychological distress. 133,134 72. Mental disorders, such as depression, anxiety, and post-traumatic stress, are related to the increasing frequency of climate events. Extreme weather events, such as floods, droughts, and storms, are becoming increas- ingly common in Haiti. They are projected to increase the rates of mental disorders. Although there is a lack of information on the incidence and prevalence of mental health disorders in Haiti, global figures show that 14 percent of the global disease burden is attributed to mental health illnesses. 135 Moreover, research shows that psychopathologies attributed to extreme weather events have increased by 17 percent, impacting about 30–40 percent of the population affected by the disaster. Research suggests that the impacts can persist up to two years after the event. 136 73. It is challenging to project mental health outcomes related to climate change. In Haiti, there is a need for improved surveillance and diagnostics, as well as specialist training and services, to meet the mental health and well-being needs of the population. Research in other countries 137 have projected levels of heat-related excess mortality for mental disorders. These estimates may not be trans- ferable directly to the context of Haiti; however, the trends between increasing temperatures and associated mental disorders have also been found with regard to self-harm and suicide rates. Moreover, other findings suggest that suicide rates increase by 0.7 percent and 3.1 percent, respectively, for a 1°C increase in the average monthly temperature. 138 74. There are many factors that influence mental health and well-being, and the nature of resilience is not fully understood. For example, there is opportunity for post-traumatic growth (PTG) following a climate change-related extreme weather event, as opposed to the inevitability of the trauma. PTG is defined by Tedeschi and Calhoun (1995) as “significant beneficial changes in cognitive and emotional life beyond levels of adaptation, psychological functioning, or life awareness that occur in the aftermath of psychological traumas that challenge previously existing assumptions about self, others, and the future.” 139 36 | Climate and Health Vulnerability Assessment: Haiti TABLE 9. Summary of the Climate Change Risks on Health Outcomes HEALTH OUTCOME RISK SUMMARY Nutrition and Food Security • Haiti is among the most food-insecure countries in the world. • 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 Diseases • In Haiti, the vectors for malaria may increase their spatial and temporal distribution, 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 and Water- related Diseases • Waterborne and water-related diseases occur throughout Haiti due to inadequate water and sanitation systems, intense precipitation, drought conditions, and specific water contaminants. • 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 Morbidity and Mortality • Haiti’s under-five-year-olds are at most risk of the predicted increases in the number of tropical nights. • 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. Climate-Related Health Risks | 37 HEALTH OUTCOME RISK SUMMARY Air Quality and Respiratory Health • The disease burden, due to poor air quality, is the second-highest contributor to DALYS across all ages. • 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 and Well-being • Increases in the occurrences of extreme weather events, such as floods, droughts, and 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. 39 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 impact the health system. The health system has managed extreme climate-related events, such as the 2016 Hurricane Matthew, as well as other severe natural hazards such as the 2010 earthquake. 143 Those climate and natural disasters impacted health infrastructures, as well as electricity, clean water, and sanitation systems. 144 The healthcare infrastructure has been severely compromised by earthquakes, hurricanes, and a lack of public expenditure in the health system. 145 77. The emergence of the Coronavirus 2019 (COVID-19) pandemic has brought with it a focus on health systems, specifically the acquisition of sufficient vaccinations for the population, as only 0.95 percent of the population is fully vaccinated. Nonetheless, Haiti has not suffered significantly during the pandemic, specifically in relation to COVID-19 deaths (827) and cases (30,473), since the start of the pandemic, as compared to other developing countries. 146 However, climate change, in combination with COVID-19, has the potential to disrupt and overwhelm health systems, including healthcare facilities and healthcare staff. This is especially important in settings that may already have weak health systems, including leadership challenges, a lack of resources, and / or limited capacity. 78. The extent to which Haiti is prepared for, and has the capacity to respond to, climate-related changes is a key modifier of climate-related health risks. In this assessment, Haiti’s adaptive capacity j to prevent and manage climate-re- lated health risks is examined according to WHO’s six health system building blocks (Figure 15). 147 These building blocks are further elaborated upon in the remainder of this section. j Adaptive capacity is defined by IPCC as “the ability of a system to adjust to climate change (including climate variability and extremes) to moderate potential damages, to take advantage of opportunities, or to cope with the consequences.” The related term, resilience, is the ability to prepare and plan for, absorb, recover from, and more successfully adapt to, adverse events. People and communities with strong adaptive capacity have greater resilience. This assessment makes use of the terms, “adaptation” and “adaptive capacity,” to encompass both terms. 40 | Climate and Health Vulnerability Assessment: Haiti LEADERSHIP AND GOVERNANCE 79. Haiti is committed to meeting the climate challenge through both adaptation and mitigation measures — coordinated and implemented by the Direction des Changements Climatiques (DCC) at MDE. Over the past decade, the government of Haiti TABLE 10. Key policies and action plans in Haiti that consider climate change challenges 2012National Health Policy, MSPP 148 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. 2012Strategic Program for Climate Resilience (SPCR), Inter-ministerial for Spatial Planning and Inter-Ministerial Committee for Land Planning 149 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. has demonstrated its political commitment and action to address climate change challenges through several global and country-level agreements and protocols — some relevant to health. Table 10 highlights the key policies and action plans in Haiti, which include consider- ations of climate change challenges, starting from 2012. FIGURE 15. WHO’s health system building blocks Service Delivery Financing Health Workforce Health Information Systems Essential Medical Products & Technologies Leadership & Governance BUILDING BLOCKS OF HEALTH SYSTEMS Source: World Health Organization, 2015, Operational Framework for Building Climate Resilient Health Systems. Adaptive Capacity | 41 2013Second communications on climate change, Direction des Changements Climatiques (DCC), MDE 151 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. 2014Haiti Sustainable Energy Roadmap, Ministère des Travaux Publics, Transports et Communications 152 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. 2015Intended Nationally Determined Contribution, MDE 153 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. 2006National Adaptation Plan of Action (NAPA), MDE 154 (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 projects 155 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. 42 | Climate and Health Vulnerability Assessment: Haiti • 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 2019National Policy to fight Climate Change, MDE 160 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. 2019National Disaster Risk Management Plan 161 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. 2021Health Master Plan 2021–2031 162 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. 2022National 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 percent 163 of the total estimated budget. HEALTH WORKFORCE 80. Haiti has challenges in building and retaining a strong health workforce, particularly in the public sector. Haiti is one of the 57 countries defined as having a crisis in human resources for health (HRH). For example, there are concerns about the quality of education, standards, and accreditation; poor career structures and skill mix in the workforce; urban-rural maldistribution, with specific issues with rural retention; insufficient and irregular salary payments, as well as a lack of medical supplies and essential resources; and poor retention 164 characterized by inter- national migration. 81. Attracting and retaining qualified health professionals is a chronic challenge, with as few as six health professionals per 10,000 people. 165 In 2018, Haiti was reported to have an estimated 2.3 medical doctors and 3.97 nurses and midwives per 10,000 population, which is below WHO’s minimum threshold for Adaptive Capacity | 43 UHC — 44.5 per 10,000. 166 In total, there were an estimated 2,606 registered doctors, 4,227 nurses, and around 197 midwives. 167 Moreover, there is a shortage of other health profes- sionals: for example, there were 1,731 medical pathologists and laboratory technicians, and by 2016, around 0.077 psychiatrists worked in the mental health sector per 100,000. 168 According to WHO, there are no environ- mental health workers in the country. The shortage is worsened by the outmigration of medical doctors and nurses due to a lack of adequate labor conditions. 169 82. The training and recruitment pipeline faces challenges. On average, 352 medical doctors, 4,234 nurses, and 75 midwives graduate from Haiti’s educational institutions each year. With bilateral cooperation agreements supporting the training of medical doctors for Haiti, the total number of medical doctors reaches approximately 500–600. 170 However, after their studies, about 24 percent of medical doctors, 87 percent of nurses, and 59 percent of midwives remain unemployed due to insuf- ficient recruitment resources. 171 83. The health workforce, particularly doctors and nurses, is more concentrated in urban areas. Eighty percent of medical staff are located in urban health facilities, leaving less than 20 percent in rural areas where half of the population lives. 172 , 173 Both the private and government health sectors face shortages of doctors, nurses, and community health workers in rural areas. Traditional medicine and healers are typically linked to local religions and widely used in areas lacking in licensed practitioners; for example, traditional birth attendants are responsible for around 75 percent of birth deliveries in the country. 174 However, there is no data on how these traditional practices and practitioners manage conditions related to climate-health risks, such as heat exposure and vector-borne and waterborne diseases, along with the management of mental health conditions. 84. Salary payment systems for health workers have curtailed health workforce capacity. Until 2018, health workers were paid by direct deposit. Widespread corruption resulted in the MSPP making salary payments by checks. However, such a process requires health workers to travel to urban centers to pick up their salary payments, thus leading to the loss of a workday and disincentivizing health workers to work in rural areas. 175 Moreover, delays in salary payments and insufficient remuneration are a common trend among health workers, constituting a primary cause of international outmigration. 176 85. NGOs are an essential part of the healthcare workforce. Organizations such as Partners in Health (PIH) have been working to improve healthcare access in Haiti since the early 1980s. The organization employs around 6,300 health staff, including 2,500 community health workers. They attend to more than 1.3 million people in primary care, maternal and child health care, HIV, tuberculosis, mental health, and more advanced care. A part of their work is focused on providing training to the health workforce; they offer six residency programs. Although PIH’s workforce has provided services during extreme weather events such as hurricanes, there is no information regarding the integration of climate change impacts on health as part of the training of their health staff. 177 86. International aid and short-term medical missions (STMMs) are common in Haiti; they help to mitigate the health workforce shortage. However, these platforms tend to 44 | Climate and Health Vulnerability Assessment: Haiti result in unregulated activities, which are not integrated into the national health strategic planning. There is a need to coordinate STMMs with local health officials, so that there can be appropriate coordination, regulation, and distribution of an accredited health workforce to areas of the greatest need. Moreover, it is pivotal to incorporate the STMMs into a climate-health adaptation national strategy. 178 87. Efforts with multilateral stakeholders, such as the United States Agency for International Development (USAID) and the Health Finance and Governance Project (HFG), have focused on evaluating and improving conditions for human resources among public and private health institutions. For example, HFG has developed guidelines and programs to improve the accreditation process of medical doctors, nurses, and community health workers through the Reconnaissance project. 179 Efforts to improve access to quality health services have prioritized the health workforce, yielding the first Plan Stratégique de Développement des Ressources Humaines pour la Santé. 180 Furthermore, HFG and USAID have worked alongside the Directorate of Human Resources within MSPP to evaluate the capacity and conditions of human resources in public and private health institutions. 181 These initiatives, supported by improvements in health financing management, seek to ameliorate workforce conditions and the retention of the human capital in the country. 182 88. There are no capacity-building programs in place that address the context of a changing climate and the capabilities of the health workforce to prepare for, prevent, as well as respond and adapt to climate change-related health risks. Haiti developed a Strategic Plan for the Development of Human Resources in the Health Sector for 2030. Among its primary goals, it seeks to strengthen the health workforce and the health system. Moreover, it aims to improve labor conditions and retention mechanisms to improve health workforce deployment in the country. However, there is no mention of climate change in this document or training to manage specific climate-related health risks. Both professional training (for example, medical and nursing schools) and continued professional training (for example, on-the-job, post-graduate, and in-service training) mechanisms lack compre- hensive information on understanding and reducing the health risks of climate change or training on disaster response, such as for floods, mudslides, and extreme events. 89. The extent to which Haiti’s health workforce has adequate knowledge, technical capacity, and resources to prevent and manage current and future climate-change-related health risks remains unknown. There is a lack of a health workforce, and even with an adequate workforce, there are not sufficient resources. Although some training materials have been developed for extreme weather events such as hurricanes, expansion is needed across climate-sensitive disease programs, including the development and adaptation of educational curricula and training materials, as well as the integration of climate change into in-service health worker and community health worker training programs. HEALTH INFORMATION AND DISEASE SURVEILLANCE SYSTEMS 90. Historically, there have been issues with incomplete data, inaccurate data, the lack of timely data collection, and parallel information systems among various partners working in health. In addition, the information Adaptive Capacity | 45 that is available is not always analyzed and used for decision-making in health planning and policy. 183 One of the main challenges is to set up and implement an effective and efficient structure that is capable of reorga- nizing and consolidating the various HIS, in order to effectively support evidence-based decision-making at all levels: institutional, local, district, and central. 91. Since June 2008, the Pan American Health Organization (PAHO) / WHO has been supporting MSPP to create a National Health Information System that will consolidate all relevant health information for use in health planning, decision-making, and action. This system will include information on morbidity, mortality, health systems, health services, human resources, and health financing at all levels of Haiti’s healthcare system. Unfortu- nately, there was a considerable setback for the health information system project, when the 2010 earthquake destroyed the MSPP building, where the Planning and Evaluation Unit was located. Information on the recent progress of the development of the system is limited. 92. There are climate-related and natural disasters information technologies relevant to health and health systems being developed in Haiti. Disaster risk management (DRM) includes evaluating, adapting, and improving early warning systems and disseminating the information. 184 Initiatives — such as Haiti Data that produces data regarding climate-related events like floods, cyclones, earthquakes, water scarcity, and landslides — are pivotal for developing climate-related health risk estimation models. They show excellent potential for improving resilience in the healthcare system. 185 Following the 2010 earthquake, key programs and services were appraised as part of the post-earthquake response and recovery planning, which has taken a central role in informing current and future strengthening and prioritization within the health sector. 186 The disease surveillance system has been expanded and strengthened, facilitated by both disease surveillance, as well as outbreak management and clinical services. 187 Nonetheless, there is still a lack of climate-in- formed programs, such as early-warning monitoring systems. Furthermore, there is also a need to establish and strengthen current initiatives monitoring and addressing nutritional risks that are being exacerbated by climate change, as food security has been a historical healthcare challenge in Haiti. ESSENTIAL MEDICAL PRODUCTS AND TECHNOLOGIES 93. In 2016, the Haiti government endorsed the essential service package (PES): it included a requirement for a range of basic health services; a list of drugs and equipment; and a minimum number of staff required for each level of care. 188 The Global Fund provides health facilities with the resources to manage cases of malaria, HIV/AIDS, and tuberculosis free of charge, and other supplies are purchased from MSPP’s storage and registered distributors, where possible. While the PES specifies the standards of imple- mentation, it does not address how they are delivered. In actuality, implementation has stagnated due to the lack of basic infrastruc- ture, resources, and skills. The healthcare system — from preventive to critical care — is inadequately equipped. Stockouts are 46 | Climate and Health Vulnerability Assessment: Haiti common in health facilities in Haiti. Another example is the powering of the solar-pow- ered refrigerator for cold chain requirements, which are available at most rural health centers and dispensaries; however, they rarely have a functioning power system to ensure a constant electricity supply. These gaps and vulnerabilities in equipment and supplies have exacerbated the impact of climate-related health risks. There is no recent information available on the implementation of the PES. HEALTH SERVICE DELIVERY 94. Healthcare delivery in Haiti remains fragile, characterized by the limited coverage of primary care services and suboptimal healthcare performance, resulting in consid- erable health vulnerability for the Haitian population. 189 Approximately 40 percent of Haiti’s population lacks access to essential health and nutrition services. 190 Geographic access to the health service is limited for the rural population, in particular. This limitation is attributed principally to the insufficient number of facilities, the difficulties in reaching the facilities, and local customs. 191 Poor facilities and service delivery in Haiti also diminish service utilization. As a result, primary care of good quality is accessible to only 23 percent of the population: 46 percent in urban areas and 5 percent in rural areas. 192 95. Extreme weather events, such as hurricanes and tropical storms, have strained the healthcare system. The increased intensity of these events has limited access to medication, medical advice, supply and cold chains, and clinic visits with appropriate healthcare personnel, thereby hampering the management of diseases and conditions. 193 96. Health infrastructure, including healthcare facilities, especially in remote areas, is also vulnerable to extreme weather events, becoming inoperable during events when they are most needed. The government’s preventive and curative services in Haiti are delivered through dispensaries, health centers without beds, health centers with beds, and hospitals equipped with intensive care units (ICUs) (Table 11). Private healthcare facilities constitute almost half of the services (46.76 percent), followed by public facilities (37.21 percent) and facilities that are a mix between public and private services (16.03 percent). 194 97. A lack of transportation and adequate roads in rural areas makes access to health facilities a challenge for around half of the total population. Not all communes 195 have all levels of health facilities, with research suggesting that distance accounts for why 37 percent of the population does not seek healthcare attention. 196 Moreover, remote villages are accessible only by foot, and roads connecting villages with towns are often unpaved and inaccessible when riverine flooding occurs. There is a lack of reliable and affordable public transportation, and national ambulance services are only available in certain zones. 197 98. A lack of healthcare system capacity exacerbates risks from climate change. Recent research shows the lack of resilience in critical care healthcare infrastructure in Haiti (see Table 2), with most of its infrastructure concentrated in urban areas. The country lacks sufficient facilities with adequate numbers of ICU beds. Only 17.4 percent of the critical care facilities are equipped with ICU beds. Consequently, 80 percent of critically ill patients in hospitals without ICU are taken care of in the emergency department, which is also inadequately equipped. 198 TABLE 11. Number of healthcare facilities, by type, across provinces DEPT. CATEGORY STATUS DEPARTMENTDISPENSARIES (%) HEALTH CENTERS WITHOUT BEDS (%) HEALTH CENTERS WITH BEDS (%) HOSPITALS (%) PUBLIC (%) PRIVATE (%) MIX (%) Artibonite 21.43 5.51 10.88 8.20 17.4412.24 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 14.624.69 7.74 Ouest 12.44 59.71 36.05 57.38 20.0052.45 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 100.00 100.00 100.00 100.00100.00100.00100.00 DISPENSARIES (NO.) HEALTH CENTERS WITHOUT BEDS (NO.) HEALTH CENTERS WITH BEDS (NO.) HOSPITALS (NO.) Total 434 345 147 122 Source: Liste des Institutions Sanitaires Du Pays (MSPP 2015). Adaptive Capacity | 47 96. Health infrastructure, including healthcare facilities, especially in remote areas, is also vulnerable to extreme weather events, becoming inoperable during events when they are most needed. The government’s preventive and curative services in Haiti are delivered through dispensaries, health centers without beds, health centers with beds, and hospitals equipped with intensive care units (ICUs) (Table 11). Private healthcare facilities constitute almost half of the services (46.76 percent), followed by public facilities (37.21 percent) and facilities that are a mix between public and private services (16.03 percent). 194 97. A lack of transportation and adequate roads in rural areas makes access to health facilities a challenge for around half of the total population. Not all communes 195 have all levels of health facilities, with research suggesting that distance accounts for why 37 percent of the population does not seek healthcare attention. 196 Moreover, remote villages are accessible only by foot, and roads connecting villages with towns are often unpaved and inaccessible when riverine flooding occurs. There is a lack of reliable and affordable public transportation, and national ambulance services are only available in certain zones. 197 98. A lack of healthcare system capacity exacerbates risks from climate change. Recent research shows the lack of resilience in critical care healthcare infrastructure in Haiti (see Table 2), with most of its infrastructure concentrated in urban areas. The country lacks sufficient facilities with adequate numbers of ICU beds. Only 17.4 percent of the critical care facilities are equipped with ICU beds. Consequently, 80 percent of critically ill patients in hospitals without ICU are taken care of in the emergency department, which is also inadequately equipped. 198 TABLE 11. Number of healthcare facilities, by type, across provinces DEPT. CATEGORY STATUS DEPARTMENTDISPENSARIES (%) HEALTH CENTERS WITHOUT BEDS (%) HEALTH CENTERS WITH BEDS (%) HOSPITALS (%) PUBLIC (%) PRIVATE (%) MIX (%) Artibonite 21.43 5.51 10.88 8.20 17.4412.24 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 14.624.69 7.74 Ouest 12.44 59.71 36.05 57.38 20.0052.45 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 100.00 100.00 100.00 100.00100.00100.00100.00 DISPENSARIES (NO.) HEALTH CENTERS WITHOUT BEDS (NO.) HEALTH CENTERS WITH BEDS (NO.) HOSPITALS (NO.) Total 434 345 147 122 Source: Liste des Institutions Sanitaires Du Pays (MSPP 2015). 99. Longer-term strategies on DRM, such as projecting climate change trends, have been identified as part of a comprehensive approach for some climate-related health risks, with the aim of reducing the future burden. The disaster risk management report 2019–2030 199 includes climate change as a critical variable for the country’s strategic planning on disaster risk reduction and management. It highlights the need to build cooperation between different governmental institutions, private initiatives, and community organizations. It also highlights the need for decentralizing health and social services to increase access to health and essential services across the national territory. 200 100. Essential infrastructure, including health-related infrastructure, must be planned after assessing the information relevant to an area’s geographical distribution, vulnerability, and hazard occurrence in order to reduce the risk of damage from climate-related events. 201 Healthcare infrastructure design needs to incorporate climate-smart features in order to reduce building damages or losses during extreme climate-related events. Protection from flooding events or hurricanes requires that existing infrastructure be guided by overall strategies for the management of water, strong winds, and floods, as well as future climate projections. Moreover, earthquake prepared- ness can also enhance climate adaptation, as there is an important crossover for strength- ening health service delivery and the overall health system capacity. 48 | Climate and Health Vulnerability Assessment: Haiti The extent to which infrastructure assessments for the health sector are being conducted, building designs are incorporating projected climate change impacts, and retrofitting measures are being carried out are still unclear. There has been no comprehensive review of the healthcare infrastructure to identify climate change-related vulnerabilities and opportuni- ties to improve its climate resilience. FINANCING 101. The budget of the government of Haiti for health is limited. Despite its recent contri- bution for the purchase of routine vaccines, the country relies heavily on international funding and out-of-pocket (OOP) expendi- tures for Haitians to have access to health services. 202 The healthcare sector has been severely compromised due to both climate and natural disasters such as earthquakes and hurricanes, and a lack of public expenditure in the health system. Public health spending decreased from 16.6 percent in 2004 to 4.4 percent as of 2017. 203 The 2018–2019 budget allocation for the health sector showed a further decline from 4.8 percent to 3.9 percent. 204 102. Although 57 percent of the health budget went to curative care and 33 percent went to preventive care 205 during the 2013–2014 period, there were no clear considerations of climate-related preventive investments. During the same period, the health budget of USD59.5 billion comprised (a) donor funds (56.7 percent), (b) OOP expenditure (30.1 percent), (c) the government’s domestic budget (9.7 percent ), and (d) the private sector (3.5 percent). By 2018, Haiti expended 7.695 percent of its total gross domestic product (GDP) on health 206 (USD64.246 expenditure per capita) and registered an increase in OOP expenditure to USD43.583 (as a percentage of total health expendi- ture). 207 It is estimated that approximately 90 percent of the health operating budget goes to the payment of workforce salaries. 208 The health expenditure budget is made on a year-to-year basis, making it difficult to plan and address structural needs in the healthcare sector. 209 103. Risk pooling in Haiti does not account for climate and health-related risks. The Office d’Assurance Accident du Travail, Maladie et Maternité (OFATMA) is a public institution offering health insurance and social protection to employees in the public and private sectors. 210 OFATMA is mandatory for formal private and public sector employees, and voluntary for those working in the informal sector. 211 The Office National d’Assurance Vieillesse (ONA) offers insurance to the elderly and disabled. 212 Private and public companies provide health coverage through OFATMA for their employees and dependents; however, these benefits constitute small, fragmented risk pools within each company. 213 In general terms, illnesses and health care costs are not evenly distributed, with some population groups facing higher health risks, which may be exacerbated by climate change. Climate change can exacerbate underlying health burdens, while increasing the potential and size of certain catastrophic financial health risks, especially among the most vulnerable. 104. Haiti’s reliance and dependence on donors / aid for health expenditure makes it vulnerable, in terms of its ability to ensure the financing sustainability of climate-health programs. For example, donor funding went from USD44 per capita in 2011 to USD15 in Adaptive Capacity | 49 2016. International financing and aid tend to be detached from a national plan. There is no systemic approach in consolidating information on contributions and programs from foreign aid and NGOs. 105. From 2011 to 2014, the country received a total of USD282 million for climate-disaster relief, being the number-one country of 35 small island developing states (SIDS). Currently, there is a total of USD1.3 billion of international funds channeled to climate change or climate-related projects. 214 Of the USD1.1 billion for long-term projects, USD773 million are focused on sustainable energy. Among most of the projects currently funded, 50 percent comprise adaptation projects, 21 percent mitigation, and 29 percent both mitigation and adaptation. 215 These funds are being distributed among four main areas: (a) food security; (b) disaster risk reduction; (c) renewables and energy; and (d) integrated water system management. 216 106. There is no evident allocation of funding by the government of Haiti that is dedicated to addressing the impact of climate change on health and health systems. Although there is a commitment in the government’s National Adaptation Plan to Climate Change and their National Plan on Disaster Risk Management, there is no precise strategic planning for climate-health finance and resource allocations for climate-related health risks and vulnerabilities. The lack of a long-term vision increases the risk of the sustainability of climate-related health projects. Building resilient health systems for climate change requires budget allocation as an integrated component in the overall planning of a national health plan. Although Haiti has prioritized climate change projects — mostly on water conservation and DRM, these efforts have not focused on the health sector. Ultimately, guidelines for integrating a climate-resilient approach for health care and public health systems are not available to inform rationalized resource allocations. 107. A total of 76 climate change-related projects 217 have been developed in Haiti; however, none of them prioritize the health sector. Although some climate change projects indirectly impact human health issues due to climate change, such as food security efforts, or water and waste management, international funding is not being used to conduct health-based adaptation measures. 108. The health co-benefits of climate change mitigation have not been adequately promoted as cost-effective options. Arguments for implementing climate change mitigation policies often focus on perceived short-term financial costs. However, cost assessments rarely account for the health co-benefits of these policies — strengthening the resilience and outcomes for human health. Therefore, additional studies are needed to quantify the longer-term cost savings from adopting the health co-benefits of climate change adaptation policies in Haiti. 50 | Climate and Health Vulnerability Assessment: Haiti TABLE 12. Summary of the health system adaptive capacity gaps for Haiti BUILDING BLOCK SUMMARY OF GAPS IN ADAPTIVE CAPACITY Leadership and Governance • Haiti is committed to meeting the climate challenge through both adaptation and 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 Disease Surveillance Systems • There are incomplete data, inaccurate data, a lack of timely data collection, and parallel health information 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 Products and Technologies • There are important gaps between policies and practice for essential medical products and technologies, including infrastructure and resources. Though there 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 Delivery • Health service delivery is challenging in Haiti, stemming from fragmentation, 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. 51 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 CLIMATE RESILIEN C E Leadership & Governance Health Workfo rc e H e a lt h F in a n c i n g C lim a te   & P r e p a r e d n e s s  & M a n a g e m e n t E m e r g e n c y H e a l t h I n f o r m e d C l i m a t e - P r o g r a m s D e trim ents E n v iro nm ental M a n a g em ent of o f H ealth Technologies& SustainableClimate Resilient & Infrastructure C lim a te   H e a lth  & R e se a rc h M o n it o r in g  & E a r ly  W a r n in g I n t e g r a t e d  R is k C a p a c i t y   & A d a p t a t i o n A s s e s s m e n t V u l n e r a b i l i t y , Service Delivery Financing Health Workforce Health Information Systems Essential Medical Products & Technologies Leadership & Governance BUILDING BLOCKS OF HEALTH SYSTEMS Source: World Health Organization, 2015, Operational Framework for Building Climate Resilient Health Systems. 52 | Climate and Health Vulnerability Assessment: Haiti 110. The CHVA recommendations are aligned with the guiding principles for the World Bank’s Strategy for Fragility, Conflict and Violence 2020–2025. 218 These principles focus on (a) addressing the drivers of fragility and short- and long-term risks, including climate-related shocks; (b) protecting essential institutions, such as MSPP, and ensuring resilient governance; (c) strength- ening the capacity of core institutions and their legitimacy; and (d) mitigating the consequences of an FCV context, which can be exacerbated by climate and health challenges, by supporting the most vulnerable communities. Furthermore, recommendations to strengthen the health system’s resiliency could also incorporate social protection systems in order to enhance human capital and reduce inequalities, contributing to reducing risks in the context of fragility and conflict in Haiti. The provision of adaptation and mitigation interventions for strengthening the health system — in response to a changing climate — needs to bolster the government’s capacity and political legitimacy in ensuring resilient systems in Haiti. LEADERSHIP AND GOVERNANCE 111. Develop a climate and health action plan based on the newly released HNAP 2022–2030. This action plan would focus on the 85 adaptation actions in the health priority area (Encadre #2) identified in the HNAP. 112. Establish a mechanism to monitor the health sector’s adaptation measures and related indicators. This mechanism would need to include the adaptation actions included in the Haiti Nationally Determined Contributions (NDC) 2.0 (2022), as well as those in the HNAP. This monitoring mechanism should be able to track the progress of the activities of the Haiti government, as well as those of its development partners. HEALTH FINANCING 113. Establish a budget line item with MSPP that is aimed at implementing adaptation measures for the health sector and providing funds for preparedness for extreme weather events. 114. Develop a monitoring system to track funds from the MSPP and its development partners that are being directed to climate and health projects and programs. This system could be intertwined with the progress tracking system of the NAP. SERVICE DELIVERY 115. Develop standard operating procedures (SOPs) that account for climate-related health risks and ensure the continuity of the provision of health services during extreme weather events. These SOPs could be developed at the facility level, focusing on primary healthcare services, and at the system level, ensuring the procurement of pharmaceutical and medical equipment in line with climate-related health risks. 116. Enhance disaster contingency planning, specifically including the deployment of medical products to aid the response to climate shocks. This would include integrating climate-related health considerations into district- and community-level disaster management plans and will need to involve the coordination between MSPP and other stakeholders (such as NGOs and community Recommendations to enhance health system resilience to climate change | 53 organizations) for organizing activities related to preparedness and emergency responses. 117. Review national building codes to incorporate the requirements of healthcare facilities by taking into consideration exposure to acute climate shocks and the need to maintain service delivery. Importantly, this review could include the incorporation of climate risk projections into these codes / permits. HEALTH WORKFORCE 118. Work with existing initiatives to incorporate climate considerations into national health worker accreditation programs. This approach could build on the continuing efforts of the former “Reconnaissance” accreditation system that has now transi- tioned to the ownership of Haitian institutions and expanded from its origins with nursing 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. HEALTH INFORMATION SYSTEMS 120. Expand the utility of Haiti Data to complement the hydromet information currently available with climate-related health information. Data sets could be complemented with targeted modeling and the important analysis of outputs, through the publication of frequent reports and recommendations, to assist policymakers and planners in the decision-making process. 121. Develop early warning systems for extreme weather events that integrate and disseminate information on climate-related health risks. These early warning systems could be linked with a centralized emergency operations center system in order to facilitate the decision-making process. It could utilize mobile telephone platforms to send timely information to health and emergency profes- sionals, and the general public. 55 ANNEXES ANNEX A. METHODS FOR ESTIMATING MOSQUITO SUITABILITY IN HAITI, UNDER RCP8.5 To demonstrate the plausible spatial distributions of the vectors of dengue and malaria, spatial models were constructed to assess the risk propensity of these diseases. Climate data are taken from the historical reference period (1986–2005), the 2030s, and the 2050s. The epidemiology of VBDs is directly influenced by environmental factors that facilitate vector development and survival. It is important to recognize that spatial modeling results are limited by the input data’s spatial resolutions and the parameterization of predictor variables, as demonstrated from the literature review including laboratory studies. Here, results are largely a function of minimum and maximum temperatures (that is, the thermal tolerance levels of vector species), as well as LULC (that is, the characteristics of the species’ preferred habitats), whose input data’s spatial resolutions are 25 km and 100 m, respectively. These resolutions provide large, rather than fine-scale, estimations of suitable breeding areas. In addition, this methodology does not incorporate sociodemographic factors, which can play an appreciable role in facilitating or curtailing vector breeding risk. To determine the population at risk of these VBDs, suitable areas were spatially overlaid with population data from the Global Human Settlement Layers (2015) to calculate the population residing in suitable areas, by region. Population data are held constant in all models, in the absence of spatial population projection information. As such, these results should be taken as a conservative estimate of the areas of Haiti presenting suitable conditions for vector breeding and suitable conditions for vector breeding where humans are present (that is, populated areas).   ANNEX B. ASSUMPTIONS ON THE COURSE OF FUTURE GLOBAL CLIMATE CHANGE  Predicting the future climate of any country requires several assumptions to be made about the direction of the future global climate. The World Bank’s CHVAs follow the RCPs developed by IPCC. They describe four scenarios along which the climate of the planet might change over the coming decades. The four RCPs are named according to the assumed level of global radiative forcing and the difference between the energy absorbed by planet Earth versus the energy reflected back into space by 2100. The radiative forcing is measured in watts per square meter, resulting in the four IPCC RCPs as follows: RCP2.6, RCP4, RCP6, and RCP8.5. Each RCP shows the planet trapping progressively higher amounts of energy from RCP2.6 (the lowest) to RCP8.5 (the highest). A wide range of factors will determine which RCP will most closely predict the course of the planet’s future climate for the rest of this century.   •Mid-range emissions (RCP4.5): This scenario is a stabilization scenario that assumes action is taken by all countries to curb climate change, resulting in a global average temperature  rise of no more than 2°C and 3°C above pre- industrial temperature levels by 2100.  •High-end emissions scenario (RCP8.5): This scenario represents the extreme end 56 | Climate and Health Vulnerability Assessment: Haiti of plausible climate change, delivering an estimated global average temperature increase of about 5–6°C by 2100 (NOAA 2021), relative to pre-industrial temperature levels. RCP8.5 is currently recognized as “business as usual.” Given today’s current environment, RCP8.5 is the most realistic scenario for the future.   For the purposes of the World Bank’s vulnerability assessments and the specific near-to-mid-term time periods — 2030s to 2050s, RCP8.5 is the most likely scenario, and it is the one being used throughout the assessment. RCP4.5 can be useful as a risk comparison to demonstrate a plausible “avoided impact” through strong mitigation efforts.   In addition to selecting the most likely scenario for the future global climate, it is also useful to define a baseline period to represent the current climate within which observed health impacts have occurred. It is also helpful to define future time periods that can be compared against this baseline, and for which assumptions or models can 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.   The baseline period covers 30 years, since this has conventionally been the length of time over which climatic conditions are measured to reduce the noise from annual or other cyclical variations. Looking to the future, 20-year time periods are used as a consequence of the accelerating pace of change of global climate, which also allow for the analysis of climate-related threats over a sufficiently proximate timescale.     •2030s: This is the 20-year period from 2020 to 2039, with 2030 as the chronological mid- point. It can be seen to represent the immediate coming years to which countries and their governments need to respond with utmost urgency.  •2050s: This is the 20-year period from 2040 to 2059, with 2050 as the chronological mid-point. It can be seen to represent a medium-term period, still well within the lifetime of current populations over which countries and govern- ments have sufficient time to make profound changes in preparation for expected threats.   57 REFERENCES 1 Intergovernmental Panel on Climate Change. 2021. Sixth Assessment Report. https://www.ipcc.ch/assessment-report/ar6/. 2 Intergovernmental Panel on Climate Change. 2021. Sixth Assessment Report. https://www.ipcc.ch/assessment-report/ar6/. 3 Robert J. Nicholls and Anny Cazenave, 2010, “Sea-Level Rise and Its Impact on Coastal Zones,” Science 328 (18): 1517–20, doi: 10.1126/ science.1185782. 4 World Bank. Climate Change Knowledge Portal. https://climateknowl- edgeportal.worldbank.org/. 5 The Emergency Events Database. https://public.emdat.be/. 6 The Emergency Events Database. https://public.emdat.be/. 7 World Bank. Climate Change Knowledge Portal. Country: Haiti. https:// climateknowledgeportal.worldbank.org/country/haiti/vulnerability. 8 Intergovernmental Panel on Climate Change. 2021. Sixth Assessment Report. https://www.ipcc.ch/assessment-report/ar6/. 9 Global Facility for Disaster Reduction and Recovery. Think Hazard. https://thinkhazard.org/en/report/108-haiti/CF. 10 Government of Haiti, World Bank, IDB (Inter-American Development Bank), and UN (the United Nations System), 2010, Republic d’Haiti: Analysis of Multiple Natural Hazards in Haiti (NATHAT), ReliefWeb, March 26, 2010, https://reliefweb.int/report/haiti/analysis-multiple-natu- ral-hazards-haiti-nathat. 11 The Emergency Events Database. https://public.emdat.be/. 12 Global Facility for Disaster Reduction and Recovery. Think Hazard. https://thinkhazard.org/en/report/108-haiti/CF . 13 David Eckstein, Vera Kunzel, and Laura Schafer, 2021, Global Climate Risk Index 2021 — Who Suffers Most from Extreme Weather Events? Weather-Related Loss Events in 2019 and 2000–2019, ReliefWeb, January 2021, https://reliefweb.int/report/world/global-climate-risk-in- dex-2021. 14 James M. Shultz, Toni Cela, Louis Herns Marcelin, Maria Espinola, Ilva Heitmann, Cludia Sanchez, Arielle Jean Pierre et al., 2016, “The Trauma Signature of 2016 Hurricane Matthew and the Psychosocial Impact on Haiti,” Disaster Health 3(4): 121–38, doi: 10.1080/21665044.2016.1263538. 15 James M. Shultz, Toni Cela, Louis Herns Marcelin, Maria Espinola, Ilva Heitmann, Cludia Sanchez, Arielle Jean Pierre et al., 2016, “The Trauma Signature of 2016 Hurricane Matthew and the Psychosocial Impact on Haiti,” Disaster Health 3(4): 121–38, doi: 10.1080/21665044.2016.1263538. 16 World Bank, 2020, Haiti: Providing Opportunities for all Haitians, Results Brief, January 8, 2020, https://www.worldbank.org/en/ results/2020/01/08/haiti-providing-opportunities-for-all-haitians. 17 Erin Hulland, Saleena Subaiya, Katilla Pierre, Nikolson Barthelemy, Jean Samuel Pierre, Amber Dismer, Stanley Juin, David fitter, and Joan Brunkard, 2018, “Increase in Reported Cholera Cases in Haiti Following Hurricane Matthew: An Interrupted Time Series Model,” The American Journal of Tropical Medicine and Hygiene 100 (2): 368–73, doi: 10.4269/ajtmh.17-0964. 18 World Bank, 2020, Haiti: Providing Opportunities for all Haitians, Results Brief, January 8, 2020, https://www.worldbank.org/en/ results/2020/01/08/haiti-providing-opportunities-for-all-haitians. 19 Macarthur Charles, Milo Richard, Mary R. Reichler, Jean Baptiste Koama, Willy Morose, and David L. Fitter, 2021, “Treatment Success for Patients with Tuberculosis Receiving Care in Areas Severely Affected by Hurricane Matthew — Haiti, 2016,” PLoS One 16 (3): e0247750, doi: 10.1371/journal.pone.0247750. 20 World Bank, 2020, Haiti: Providing Opportunities for all Haitians, Results Brief, January 8, 2020, https://www.worldbank.org/en/ results/2020/01/08/haiti-providing-opportunities-for-all-haitians. 21 Jayaka D. Campbell, Michael A. Taylor, Arnoldo Bezanilla-Morlot, Tannecia S. Stephenson, Abel Centella-Artola, Leonardo A. Clarke, and Kimberly A. Stephenson, 2021, “Generating Projections for the Caribbean at 1.5, 2.0, and 2.5◦C from High-Resolution Ensemble,” Atmosphere 12 (3): 328, doi: 10.3390/atmos12030328. 22 Tannecia S. Stephenson and Jhordanne J. Jones, 2017, “Impacts of Climate Change on Extreme Events in the Coastal and Marine Environments of Caribbean Small Island Developing States (SIDS),” Caribbean Climate Change Report Card: Science Review: 10–22. 23 Bhawan Singh, Marc J. Cohen. 2014. Climate Change Resilience: The case of Haiti. Oxam Research Reports. https://www-cdn.oxfam.org/ s3fs-public/file_attachments/rr-climate-change-resilience-haiti-260314- en_2.pdf. 24 Thomas R. Knutson, John L. McBride, Johnny Chan, Kerry Emanuel, Greg Holland, Chris Landsea, Isaac Held, James P. Kossin, A. K. Srivastava, and Masato Sugi, 2010, “Tropical Cyclones and Climate Change,” Nature Geoscience 3 (3): 157–63, doi: 10.1038/ngeo779. 25 World Bank. Climate Change Knowledge Portal. Country: Haiti. https:// climateknowledgeportal.worldbank.org/country/haiti/vulnerability. 26 Jane A. Palmer, “Slippery Slope: Could Climate Change Lead to More Landslides?” Eos, November 23, 2020, doi: 10.1029/2020EO151418. 27 Global Facility for Disaster Reduction and Recovery and Climate Investment Fund. 2011. Vulnerability, Risk Reduction, and Adaptation to Climate Change. https://climateknowledgeportal.worldbank.org/sites/ default/files/2018-10/wb_gfdrr_climate_change_country_profile_for_ HTI.pdf. 28 David Alvarez Castro, 2013 ‘’Landslide Risks in Haiti and Land Management in Port au Prince,” Master’s thesis, Universidad Politécnica de Madrid. https://oa.upm.es/21673/2/TESIS_MASTER_DAVID_ ALVAREZ_CASTRO.pdf. 29 David Alvarez Castro, 2013 ‘’Landslide Risks in Haiti and Land Management in Port au Prince,” Master’s thesis, Universidad Politécnica de Madrid. https://oa.upm.es/21673/2/TESIS_MASTER_DAVID_ ALVAREZ_CASTRO.pdf. 30 Global Facility for Disaster Reduction and Recovery and Climate Investment Fund. 2011. Vulnerability, Risk Reduction, and Adaptation to Climate Change. https://climateknowledgeportal.worldbank.org/sites/ default/files/2018-10/wb_gfdrr_climate_change_country_profile_for_ HTI.pdf. 31 The Emergency Events Database. https://public.emdat.be/. 32 The Emergency Events Database. https://public.emdat.be/. 33 Bhawan Singh, Marc J. Cohen. 2014. Climate Change Resilience: The case of Haiti. Oxam Research Reports. https://www-cdn.oxfam.org/ s3fs-public/file_attachments/rr-climate-change-resilience-haiti-260314- en_2.pdf. 34 World Bank. Climate Change Knowledge Portal. https://climateknowl- edgeportal.worldbank.org/. 35 World Bank. Climate Change Knowledge Portal. https://climateknowl- edgeportal.worldbank.org/. 36 Intergovernmental Panel on Climate Change. WGI Interactive Atlas. https://interactive-atlas.ipcc.ch/. 37 Global Facility for Disaster Reduction and Recovery. Think Hazard. https://thinkhazard.org/en/report/108-haiti/CF. 38 Madeleine Rubenstein. 2012. Climate Change in Haiti. General Earth Institute. https://news.climate.columbia.edu/2012/02/01/climate-change- in-haiti/. 39 Global Facility for Disaster Reduction and Recovery. Think Hazard. https://thinkhazard.org/en/report/108-haiti/CF. 40 Global Facility for Disaster Reduction and Recovery. Think Hazard. https://thinkhazard.org/en/report/108-haiti/CF. 41 République d’Haïti Ministère de la Santé Publique et de la Population, 2021, Plan Directeur Santé: 2021–2031, 7, HTI-111772.pdf (ilo.org). 58 | Climate and Health Vulnerability Assessment: Haiti 42 Institute for Health Metrics and Evaluation. 2019. https://vizhub. healthdata.org/gbd-compare/. 43 Institute for Health Metrics and Evaluation. 2019. https://vizhub. healthdata.org/gbd-compare/. 44 Institute for Health Metrics and Evaluation. 2019. https://vizhub. healthdata.org/gbd-compare/. 45 Peters, A., Schneider, A. Cardiovascular risks of climate change. Nat Rev Cardiol 18, 1–2 (2021). https://doi.org/10.1038/s41569-020-00473-5. 46 Michael Marmot Jessica Allen, Peter Goldblatt, Tammy Boyce, Di McNeish, Mike Grady, and Ilaria Geddes, 2010, Fair Society, Healthy Lives: The Marmot Review, https://www.instituteofhealthequity.org/ resources-reports/fair-society-healthy-lives-the-marmot-review/fair-soci- ety-healthy-lives-full-report-pdf.pdf. 47 The Emergency Events Database. https://public.emdat.be/. 48 Institute for Health Metrics and Evaluation. 2019. https://vizhub. healthdata.org/gbd-compare/. 49 World Bank. 2017. Rapidly Assessing the Impact of Hurricane Matthew in Haiti. https://www.worldbank.org/en/results/2017/10/20/rapidly-assess- ing-the-impact-of-hurricane-matthew-in-haiti. 50 World Bank. Climate Change Knowledge Portal. Country: Haiti. https:// climateknowledgeportal.worldbank.org/country/haiti/vulnerability. 51 The Emergency Events Database. https://public.emdat.be/. 52 World Bank. Climate Change Knowledge Portal. Country: Haiti. https:// climateknowledgeportal.worldbank.org/country/haiti/vulnerability. 53 Republique D’ Haiti - Ministère De L’Environnement. 2006. Plan D’Action National D’Adaptation (PANA). https://unfccc.int/resource/docs/napa/ hti01f.pdf. 54 J. I. Macdiarmid and S. Whybrow S., 2019, “Nutrition from a Climate Change Perspective,” Proceedings of the Nutrition Society 78 (3): 380–7, doi: 10.1017/S0029665118002896. 55 FAO (Food and Agriculture Organization of the United Nations), IFAD (International Fund for Agricultural Development), UNICEF (United Nations Children’s Fund), WFP (World Food Programme), and WHO (World Health Organization). The State of Food Security and Nutrition in the World — Transforming Food Systems for Food Security, Improved Nutrition, and Affordable Healthy Diets for all, Rome, Italy: FAO, doi: 10.4060/cb4474en. 56 Integrated Food Security Phase Classification (IPC). 2021. IPC Haiti Alert September 2021. https://www.ipcinfo.org/ipcinfo-website/alerts-archive/ issue-44/en/. 57 Integrated Food Security Phase Classification (IPC). 2021. IPC Haiti Alert September 2021. https://www.ipcinfo.org/ipcinfo-website/alerts-archive/ issue-44/en/. 58 Food and Agriculture Organization. 2021. The impact of disasters and crises on agriculture and food security. https://www.fao.org/3/cb3673en/ cb3673en.pdf. 59 Food and Agriculture Organization. 2021. The impact of disasters and crises on agriculture and food security. https://www.fao.org/3/cb3673en/ cb3673en.pdf. 60 Mbow, C., C. Rosenzweig, L.G. Barioni, T.G. Benton, M. Herrero, M. Krishnapillai, E. Liwenga, P. Pradhan, M.G. Rivera-Ferre, T. Sapkota, F.N. Tubiello, Y. Xu, 2019: Food Security. In: Climate Change and Land: an IPCC special report on climate change, desertification, land degradation, sustainable land management, food security, and greenhouse gas fluxes in terrestrial ecosystems [P.R. Shukla, J. Skea, E. Calvo Buendia, V. Masson-Delmotte, H.-O. Pörtner, D.C. Roberts, 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, E. Huntley, K. Kissick, M. Belkacemi, J. Malley, (eds.)]. https://doi. org/10.1017/9781009157988.007. 61 World Food Programme. 2016. Haiti Urban Food Security Assessment. https://documents.wfp.org/stellent/groups/public/documents/ena/ wfp287802.pdf?_ga=2.253165386.2130901058.1695244007- 361008908.1695244007. 62 Global Hunger Index. 2019. Haiti: A closer look at hunger and undernutrition. https://www.globalhungerindex.org/case-stud- ies/2019-haiti.html. 63 United States Agency of International Development. 2018. Haiti: Nutrition Profile. https://2017-2020.usaid.gov/sites/default/files/ documents/1864/Haiti-Nutrition-Profile-Mar2018-508.pdf. 64 International Trade Organization. Haiti Country Commercial Guide. https://www.trade.gov/country-commercial-guides/haiti-agricultural-sec- tor. 65 Famine Early Warning Systems Network. 2021. Key Messages: Haiti. https://fews.net/latin-america-and-caribbean/haiti/key-message-update/ january-2022. 66 USAID, 2020, Haiti: Climate Risks to Resilience Food Security in Bureau for Humanitarian Assistance Geographies — Haiti, ReliefWeb, September 2020, https://reliefweb.int/report/haiti/haiti-climate-risks-re- silience-food-security-bureau-humanitarian-assistance-geographies. 67 Global Facility for Disaster Reduction and Recovery. Think Hazard. https://thinkhazard.org/en/report/108-haiti/CF. 68 Mbow, C., C. Rosenzweig, L.G. Barioni, T.G. Benton, M. Herrero, M. Krishnapillai, E. Liwenga, P. Pradhan, M.G. Rivera-Ferre, T. Sapkota, F.N. Tubiello, Y. Xu, 2019: Food Security. In: Climate Change and Land: an IPCC special report on climate change, desertification, land degradation, sustainable land management, food security, and greenhouse gas fluxes in terrestrial ecosystems [P.R. Shukla, J. Skea, E. Calvo Buendia, V. Masson-Delmotte, H.-O. Pörtner, D.C. Roberts, 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, E. Huntley, K. Kissick, M. Belkacemi, J. Malley, (eds.)]. https://doi. org/10.1017/9781009157988.007. 69 Smith, K.R. et al. 2014. Human Health: impacts, adaptation and co-benefits. In: Climate Change 2014: Impacts, Adaptation, and Vulnerability. Part A: Global and Sectoral Aspects. Contribution of Working Group II to the Fifth Assessment Report of the Intergovernmen- tal Panel on Climate Change. 70 Institute for Health Metrics and Evaluation. 2019. https://vizhub. healthdata.org/gbd-compare/. 71 United Nations International Children’s Emergency Fund. 2021. Haiti earthquake: over half million children at risk of waterborne diseases. https://www.unicef.org/lac/en/press-releases/haiti-earthquake-over-half- million-children-in-risk-of-waterborne-diseases. 72 Erin Hulland, Saleena Subaiya, Katilla Pierre, Nikolson Barthelemy, Jean Samuel Pierre, Amber Dismer, Stanley Juin, David fitter, and Joan Brunkard, 2018, “Increase in Reported Cholera Cases in Haiti Following Hurricane Matthew: an Interrupted Time Series Model,” The American Journal of Tropical Medicine and Hygiene 100 (2): 368–73, doi: 10.4269/ajtmh.17-0964. 73 Levy K, Smith SM, Carlton EJ. Climate Change Impacts on Waterborne Diseases: Moving Toward Designing Interventions. Curr Environ Health Rep. 2018 Jun;5(2):272-282. doi: 10.1007/s40572-018-0199-7. PMID: 29721700; PMCID: PMC6119235. 74 Kolstad EW, Johansson KA. Uncertainties associated with quantifying climate change impacts on human health: a case study for diarrhea. Environ Health Perspect. 2011 Mar;119(3):299-305. doi: 10.1289/ehp.1002060. Epub 2010 Oct 6. PMID: 20929684; PMCID: PMC3059990. 75 United Nations International Children’s Emergency Fund. 2016. Race against time to prevent spread of waterborne diseases in hurricane-hit areas as rainy season starts in Haiti. https://www.unicef.org/ press-releases/race-against-time-prevent-spread-waterborne-diseases- hurricane-hit-areas-rainy. 76 Erin Hulland, Saleena Subaiya, Katilla Pierre, Nikolson Barthelemy, Jean Samuel Pierre, Amber Dismer, Stanley Juin, David fitter, and Joan Brunkard, 2018, “Increase in Reported Cholera Cases in Haiti Following Hurricane Matthew: An Interrupted Time Series Model,” The American Journal of Tropical Medicine and Hygiene 100 (2): 368–73, doi: 10.4269/ajtmh.17-0964. 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. References | 59 78 Daniele Lantagne, G. Balakrish Nair, Claudio Lanata, and Alejandro Cravioto, 2014, “The Cholera Outbreak in Haiti: Where and How Did It Begin?” Current Topics in Microbiology and Immunology 379: 145–64, doi: 10.1007/82_2013_331. 79 Par Claudy Junior Pierre. 2022. Trois ans sans cholera, Haiti attend son certificate d’élimination. Le Nouvelliste. https://lenouvelliste.com/ article/234070/trois-ans-sans-cholera-haiti-attend-son-certificat-delimi- nation.  80 Cuellar-Martinez, T., Ruiz-Fernández, A. C., Alonso-Hernández, C., Amaya-Monterrosa, O., Quintanilla, R., Carrillo-Ovalle, H. L., Arbeláez M, N., Díaz-Asencio, L., Méndez, S. M., Vargas, M., Chow-Wong, N. F., Valerio-Gonzalez, L. R., Enevoldsen, H., & Dechraoui Bottein, M.-Y. (2018). Addressing the Problem of Harmful Algal Blooms in Latin America and the Caribbean- A Regional Network for Early Warning and Response. Frontiers in Marine Science, 5. https://www.frontiersin.org/ articles/10.3389/fmars.2018.00409. 81 Paerl, H. W., Hall, N. S., & Calandrino, E. S. (2011). Controlling harmful cyanobacterial blooms in a world experiencing anthropogenic and climatic-induced change. Science of The Total Environment, 409(10), 1739–1745. https://doi.org/10.1016/j.scitotenv.2011.02.001. 82 Haiti Libre. 2015. Haiti – ALERT: Algae invade the coast of the Great South. https://www.haitilibre.com/en/news-16193-haiti-alert-algae-in- vade-the-coast-of-the-great-south.html. 83 Haiti Libre. 2015. Haiti – ALERT: Algae invade the coast of the Great South. https://www.haitilibre.com/en/news-16193-haiti-alert-algae-in- vade-the-coast-of-the-great-south.html. 84 Andrea K Boggild, Mary Elizabeth Wilson. 2019. What every travel medicine practitioner needs to know about Sargassum weed: five key points, Journal of Travel Medicine, Volume 26, Issue 7, taz048, https:// doi.org/10.1093/jtm/taz048. 85 ANSES. 2018. Sargassum seaweed: limit the exposure of residents and workers to hydrogen sulphide. https://www.anses.fr/en/content/sar- gassum-seaweed-limit-exposure-residents-and-workers-hydrogen-sul- phide. 86 Kristie L. Ebi, Nicholas H. Ogden, Jan C. Semenza, and Alistair Woodward, 2017, “Detecting and Attributing Health Burdens to Climate Change,” Environmental Health Perspectives 125 (8): 85004, doi: 10.1289/EHP1509. 87 Katie M. Westby, Solny A. Adalsteinsson, Elizabeth G. Biro, Alexis J. Beckermann, and Kim A. Medley, 2021, “Aedes Albopictus Populations and Larval Habitat Characteristics Across the Landscape: Significant Differences Exist between Urban and Rural Land Use Types,” Insects 12 (3): 196, doi: 10.3390/insects12030196. 88 London School of Hygiene & Tropical Medicine. World Malaria Day 2021 – Haiti. https://www.lshtm.ac.uk/research/centres/malaria-centre/world- malaria-day-2021-haiti. 89 London School of Hygiene & Tropical Medicine. World Malaria Day 2021 – Haiti. https://www.lshtm.ac.uk/research/centres/malaria-centre/world- malaria-day-2021-haiti . 90 World Health Organization. 2021. World Malaria Report. https://www. who.int/teams/global-malaria-programme/reports/world-malaria-re- port-2021. 91 Institute of Health Metrics and Evaluation. 2019. https://vizhub. healthdata.org/gbd-compare/. 92 Center for Disease Control and Prevention. Haiti - Chapter 10 - 2020 Yellow Book | Travelers’ Health. 93 London School of Hygiene & Tropical Medicine. World Malaria Day 2021 – Haiti. https://www.lshtm.ac.uk/research/centres/malaria-centre/world- malaria-day-2021-haiti. 94 Boncy, P.J., Adrien, P., Lemoine, J.F. et al. Malaria elimination in Haiti by the year 2020: an achievable goal?. Malar J 14, 237 (2015). https://doi. org/10.1186/s12936-015-0753-9. 95 Jules JR, Alencar J, Suárez-Mutis MC, Baptiste EJ, Albuquerque H, Rosa-Freitas MG, Raccurt C, Oliveira RL, Silva-do-Nascimento TF. 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. 96 Boncy, P.J., Adrien, P., Lemoine, J.F. et al. Malaria elimination in Haiti by the year 2020: an achievable goal?. Malar J 14, 237 (2015). https://doi. org/10.1186/s12936-015-0753-9. 97 Stephanie J. Salyer, Esther M. Ellis, Corvil Salomon, Christopher Bron, Stanley Juin, Ryan R. Hemme, and Elizabeth Hunsperger et al., 2014, “Dengue Virus Infections among Haitian and Expatriate Non-Govern- mental Organization Workers—Léogane and Port-au-Prince, Haiti, 2012,” PLoS Neglected Tropical Diseases 8 (10): e3269, doi: 10.1371/journal. pntd.0003269. 98 Meghan Rioth, Carole Anne Beauharnais, Francine Noel, Mine R. Ikizler, Sapna Mehta, Yuwei Zhu, Carole A. Long, Jean W. Pape, and Peter F. Wright, 2011, “Serologic Imprint of Dengue Virus in Urban Haiti: Characterization of Humoral Immunity to Dengue in Infants and Young Children,” The American Journal of Tropical Medicine and Hygiene 84 (4): 630–6, doi: 10.4269/ajtmh.2011.10-0323. 99 Balthazard-Accou, K., François Millien, M., Michel, D., Jean, G., Telcy, D., & Emmanuel, E. 2021. Vector-Borne Diseases and Climate Change in the Environmental Context in Haiti. IntechOpen. doi: 10.5772/ intechopen.96037. 100 Center for Disease Control and Prevention. Haiti - Chapter 10 - 2020 Yellow Book | Travelers’ Health. 101 Maxime Chazal, Guillaume Beauclair, Ségolène Gracias, Valérie Najburg, Etienne Simon-Lorière, Frédéric Tangy, Anastassia V. Komarova, and Nolwenn Jouvenet, 2018, “RIG-I Recognizes the 5′ Region of Dengue and Zika Virus Genomes,” Cell Reports 24 (2): 320–8. 102 Zika Virus—A Public Health Emergency of International Concern | Global Health | JAMA Neurology | JAMA Network. 103 Ito Journel, Lesly L. Andrécy, Dudley Metellus, Jean S. Pierre, Rose Murka Faublas, Stanley Juin, Amber M. Dismer et al., 2017, “Transmission of Zika Virus — Haiti, October 12, 2015–September 10, 2016,” Morbidity and Mortality Weekly Report 66 (6): 172–6, doi: 10.15585/mmwr.mm6606a4. 104 Balthazard-Accou, K., François Millien, M., Michel, D., Jean, G., Telcy, D., & Emmanuel, E. 2021. Vector-Borne Diseases and Climate Change in the Environmental Context in Haiti. IntechOpen. doi: 10.5772/ intechopen.96037. 105 Kovats, R. S., & Hajat, S. (2008). Heat Stress and Public Health: A Critical Review. Annual Review of Public Health, 29(1), 41–55. https://doi. org/10.1146/annurev.publhealth.29.020907.090843. 106 Qi Zhao, Shanshan Li, Micheline S. Z. S. Coelho, Paulo H. N. Saldiva, Kejia Hu, Rachel R. Huxley, Michael J. Abramson, and Yuming Guo, 2019, “The Association between Heatwaves and Risk of Hospitalization in Brazil: A Nationwide Time Series Study between 2000 and 2015,” PLOS Medicine 16 (2): e1002753, doi: 10.1371/journal.pmed.1002753. 107 McGregor, G., Bone, A., & Pappenberger, F. 2017. Meteorological risk: extreme temperatures. In: Poljanšek, K., Marín Ferrer, M., De Groeve, T., Clark, I. (Eds.), 2017. Science for disaster risk management 2017: knowing better and losing less. EUR 28034 EN, Publications Office of the European Union, Luxembourg, ISBN 978-92-79-60678-6, doi:10.2788/688605, JRC102482. https://ghhin.org/wp-content/uploads/ McGregor-et-al-2017-Extreme-Temperatures.pdf. 108 World Health Organization. 2021. Climate Change and Health. https:// www.who.int/news-room/fact-sheets/detail/climate-change-and-health. 109 Intergovernmental Panel on Climate Change. WGI Interactive Atlas. https://interactive-atlas.ipcc.ch/. 110 Institute for Health Metrics and Evaluation. 2019. https://vizhub. healthdata.org/gbd-compare/ . 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, 282–290 (2018). https://doi.org/10.1038/s41558-018-0102-4. 112 Thompson R, Hornigold R, Page L, Waite T. Associations between high ambient temperatures and heat waves with mental health outcomes: a systematic review. Public Health. 2018 Aug;161:171-191. doi: 10.1016/j. puhe.2018.06.008. Epub 2018 Jul 12. PMID: 30007545. 60 | Climate and Health Vulnerability Assessment: Haiti 113 Thompson R, Hornigold R, Page L, Waite T. Associations between high ambient temperatures and heat waves with mental health outcomes: a systematic review. Public Health. 2018 Aug;161:171-191. doi: 10.1016/j. puhe.2018.06.008. Epub 2018 Jul 12. PMID: 30007545. 114 Solomon M. Hsiang, Marshall Burke, and Edward Miguel, 2013, “Quantifying the Influence of Climate on Human Conflict,” Science 341 (6151), doi: 10.1126/science.1235367. 115 Obradovich N, Migliorini R, Mednick SC, Fowler JH. Nighttime temperature and human sleep loss in a changing climate. Sci Adv. 2017 May 26;3(5):e1601555. doi: 10.1126/sciadv.1601555. PMID: 28560320; PMCID: PMC5446217. 116 Daniel J. Gottlieb, Naresh M. Punjabi, Ann B. Newman, Helaine E. Resnick, Susan Redline, Carol M. Baldwin, F. Javier Nieto, 2005, “Association of Sleep Time with Diabetes Mellitus and Impaired Glucose Tolerance,” Archives of Internal Medicine 165 (8): 863–7, doi: 10.1001/ archinte.165.8.863. 117 Najib T. Ayas, David P. White, JoAnn E. Manson, Meir J. Stampfer, Frank E. Speizer, Atul Malhotra, Frank B. Hu, 2003, “A Prospective Study of Sleep Duration and Coronary Heart Disease in Women,” Archives of Internal Medicine 163 (2): 205–9, doi:10.1001/archinte.163.2.205. 118 Chiara Baglioni, Gemma Battagliese, Bernd Feige, Kai Spiegelhalder, Christoph Nissen, Ulrich Voderholzer, Caterina Lombardo, and Dieter Riemann, 2011, “Insomnia as a Predictor of Depression: A Meta-Analytic Evaluation of Longitudinal Epidemiological Studies,” Journal of Affective Disorders 135: 10–9, doi: 10.1016/j.jad.2011.01.011. 119 Flavie Waters and Romola S. Bucks, 2011, “Neuropsychological Effects of Sleep Loss: Implication for Neuropsychologists,” Journal of the International Neuropsychological Society 17 (4): 571–86, doi: 10.1017/ S1355617711000610. 120 P. A. Hancock & I. Vasmatzidis (2003) Effects of heat stress on cognitive performance: the current state of knowledge, International Journal of Hyperthermia, 19:3, 355-372, DOI: 10.1080/0265673021000054630. 121 International Labour Organization. 2019. Working on a Warmer Planet: The impact of heat stress on labour productivity and decent work. https://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/--- publ/documents/publication/wcms_711919.pdf. 122 International Labour Organization. 2019. Working on a Warmer Planet: The impact of heat stress on labour productivity and decent work. https://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/--- publ/documents/publication/wcms_711919.pdf. 123 Kahn Vohra, Alina Vodonos, Joel Schwartz, Eloise A. Marais, Melissa P. Sulprizio, and Loretta J. Mickley, 2021, “Global Mortality from Outdoor Fine Particle Pollution Generated by Fossil Fuel Combustion: Results from GEOS-Chem,” Environmental Research 195 (110754), doi: 10.1016/j. envres.2021.110754. 124 Nick Watts, Markus Amann, Nigel Arnell, Sonja Ayeb-Karlsson, Kristine Belesova, Maxwell Boykoff, Peter Byass et al., 2019, “The 2019 Report 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,” Lancet 394 (10211): 1836–78, doi: 10.1016/S0140-6736(19)32596-6. 125 (Gangoiti et al., 2001; Stohl et al., 2001; Buchanan et al., 2002; Chan et 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., 2003; Unsworth et al., 2003; Kato et al., 2004; Liang et al., 2004; Tu et al., 2004). 126 Institute for Health Metrics and Evaluation. 2019. https://vizhub. healthdata.org/gbd-compare/. 127 Institute for Health Metrics and Evaluation. 2019. https://vizhub. healthdata.org/gbd-compare/. 128 Health Effects Institute, 2020, State of Global Air/2020: A Special Report on Global Exposure to Air Pollution and Its Health Impacts, Boston, MA: HEI, https://fundacionio.com/wp-content/uploads/2020/10/ soga-2020-report.pdf. 129 Health Effects Institute. 2020. State of Global Air 2020. Data source: Global Burden of Disease Study 2019. IHME, 2020.. 130 WHO published revised air quality guidelines on 22 September 2021 — the first major update of standards in 15 years. 131 Institute for Health Metrics and Evaluation. 2019. https://vizhub. healthdata.org/gbd-compare/. 132 Katie Hayes and Blake Poland, 2018, “Addressing Mental Health in a Changing Climate: Incorporating Mental Health Indicators into Climate Change and Health Vulnerability and Adaptation Assessments,” International Journal of Environmental Research and Public Health 15 (9): 1806, doi: 10.3390/ijerph15091806. 133 Clayton, S., Manning, C. M., Speiser, M., & Hill, A. N. 2021. Mental Health and Our Changing Climate: Impacts, Inequities, Responses. Washington, D.C.: American Psychological Association, and ecoAmerica. 134 Leah Emily James, Courtney Welton-Mitchell, John Roger Noel, and Alexander Scott James, 2020, “Integrating Mental Health and Disaster Preparedness in Intervention: A Randomized Controlled Trial with Earthquake and Flood-Affected Communities in Haiti,” Psychological Medicine 50 (2): 342–52, Integrating mental health and disaster preparedness in intervention: a randomized controlled trial with earthquake and flood-affected communities in Haiti | Psychological Medicine | Cambridge Core. 135 World Health Organization. Mental Health Gap Action Programme. https://www.who.int/teams/mental-health-and-substance-use/ treatment-care/mental-health-gap-action-programme#:~:text=The%20 WHO%20Mental%20Health%20Gap,low%2D%20and%20middle%2Din - come. 136 Elizabeth Rataj, Katharina Kunzweiler, amd Susan Garthus-Niegel, 2016, “Extreme Weather Events in Developing Countries and Related Injuries and Mental Health Disorders — A Systematic Review,” BMC Public Health 16 (Article 1020), doi: 10.1186/s12889-016-3692-7. 137 Shaohua Gu, Liang Zhang, Shiqiang Sun, Xiaofeng Wang, Beibei Lu, Hangtao Han, Jun Yang, and Aihong Wang, 2020, “Projections of Temperature-Related Cause-Specific Mortality under Climate Change Scenarios in a Coastal City of China,” Environment International 143: 105889, doi: 10.1016/j.envint.2020.105889. 138 Marshall Burke, Felipe González, Patrick Baylis, Sam Heft-Neal, Ceren Baysan, Sanjay Basu, and Solomon Hsiang, 2018, “Higher Temperatures Increase Suicide Rates in the United States and Mexico,” Nature Climate Change 8: 723–9, doi: 10.1038/s41558-018-0222-x. 139 Douglas Paton, 2006, “Posttraumatic Growth in Disaster and Emergency Work,” in Handbook of Posttraumatic Growth: Research and Practice, edited by Lawrence G. Calhoun and Richard G. Tedeschi, 225–47, New York, NY: Taylor and Francis Group, IJERPH | Free Full-Text | Addressing Mental Health in a Changing Climate: Incorporating Mental Health Indicators into Climate Change and Health Vulnerability and Adaptation Assessments | HTML (mdpi.com). 140 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. 141 Frontline Health Project. 2020. “The community health system in Haiti: An overview,” brief. Washington, DC: Population Council. 142 Gouvernement de la République D’Haiti. Plan Stratégique de Développement D’Haiti: Pays Émergent en 2030. https://observato- rioplanificacion.cepal.org/sites/default/files/plan/files/Haiti_PLAN_ STRATÉGIQUE_de_developpement.pdf. 143 United States Agency for International Development. 2020. Haiti Health Fact Sheet – January 2020. https://2017-2020.usaid.gov/ documents/1862/usaidhaiti-health-fact-sheet-january-2020. 144 United States Agency for International Development. 2020. Haiti Health Fact Sheet – January 2020. https://2017-2020.usaid.gov/ documents/1862/usaidhaiti-health-fact-sheet-january-2020. 145 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 Bank Group. http://documents.worldbank.org/curated/ en/393291498246075986/summary-report. 146 Johns Hopkins. Coronavirus Resource Center. https://coronavirus.jhu. edu/region/haiti. 147 World Health Organization. 2015. Operational framework for building climate resilient health systems. https://www.who.int/publications/i/item/ operational-framework-for-building-climate-resilient-health-systems. References | 61 148 Gouvernement de la République D’Haiti – Ministere de la Sante Publique et de la Population. 2012. Politique Nationale de Sante. https:// mspp.gouv.ht/site/downloads/PNS%2021juillet%20version%20finale.pdf. 149 Climate Investment Funds. 2013. Strategic Program for Climate Resilience for Haiti. https://www.cif.org/sites/default/files/PPCR_ SC.12_4_Strategic_Program_for_Climate_Resilience_for_Haiti..pdf. 150 Climate Investment Funds. Haiti. https://www.cif.org/country/haiti. 151 Gouvernement de la République D’Haiti – Ministere De L’Environne- ment. Deuxieme Communication Nationale Sur Les Changements Climatiques. 152 http://energyaccess.org/wp-content/uploads/2015/05/Haiti-Road- map-French-Publication-file.pdf. 153 Gouvernement de la République D’Haiti. Intended Nationally Determined Contributions (INDCs). https://www4.unfccc.int/sites/ submissions/indc/Submission%20Pages/submissions.aspx. 154 Gouvernement de la République D’Haiti – Ministere De L’Environne- ment. Plan D’Action National D’Adaptation (PANA). https://unfccc.int/ resource/docs/napa/hti01f.pdf. 155 UNDP. 2018. National Adaptation Plans in Focus: Lessons from Haiti. https://www.ldc-climate.org/wp-content/uploads/2018/07/haiti_nap_ country_briefing_final_online1.pdf. 156 Global Environment Facility. 2009. Haiti: Strengthenind Adaptive Capacities to Address Climate Change Threats on Sustainable Development Strategies for Coastal Communities. https://www. uncclearn.org/wp-content/uploads/library/gef41_0.pdf. 157 Climate Funds Update. Pilot Program for Climate Resilience. https://cli- matefundsupdate.org/the-funds/pilot-program-for-climate-resilience-2/. 158 United Nations Development Program. 2018. National Adaptation Plan in Focus. https://www.ldc-climate.org/wp-content/uploads/2018/07/ haiti_nap_country_briefing_final_online1.pdf. 159 United Nations Development Program. 2018. National Adaptation Plan in Focus. https://www.ldc-climate.org/wp-content/uploads/2018/07/ haiti_nap_country_briefing_final_online1.pdf. 160 Gouvernement de la République D’Haiti – Ministere De L’Environne- ment. 2019. Politique Nationale de Lutte Contre Les Changements Climatiques. https://mde.gouv.ht/phocadownload/PNCC-HAITI-2019%20 Final.pdf. 161 Gouvernement de la République D’Haiti. 2019. Plan National de Gestion des Risques de Désastre 2019 – 2030. https://www.preventionweb.net/ files/72907_plannationaldegestiondesrisquesdeds.pdf. 162 Gouvernement de la République D’Haiti – Ministère de la Santé publique et de la population. 2021. Plan Directeur Santé (2021-2031). https://www.ilo.org/dyn/natlex/natlex4.detail?p_lang=en&p_ isn=111772&p_count=5&p_classification=01. 163 USD13,475,000 of USD980,015,184, or 1.37 percent. 164 Whitney Joseph. (n.d.) The Effect of Brain Drain on Haiti. https://api. drum.lib.umd.edu/server/api/core/bitstreams/ec94a237-6cdf-4c9a- abb9-693162b42a0f/content. 165 United States Agency for International Development. 2020. Haiti Health Fact Sheet – January 2020. https://2017-2020.usaid.gov/ documents/1862/usaidhaiti-health-fact-sheet-january-2020. 166 World Health Organization. 2016. Health Workforce Requirements for Universal Health Coverage and the Sustainable Development Goals. https://iris.who.int/bitstream/handle/10665/250330/9789241511407-eng. pdf. 167 World Health Organization. Global Health Observatory data repository. https://apps.who.int/gho/data/node.main.HWFGRP_0180?lang=en. 168 World Health Organization. Global Health Observatory data repository. https://apps.who.int/gho/data/node.main.HWFGRP_0180?lang=en. 169 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. 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. org/haiti-plan-strategique-de-developpement-des-ressources-hu- maines-pour-la-sante-2030/. 171 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. org/haiti-plan-strategique-de-developpement-des-ressources-hu- maines-pour-la-sante-2030/. 172 Gouvernement de la République D’Haiti – Ministère de la Santé publique et de la population. 2015. Liste des Institutions Sanitaires du Pays. https://mspp.gouv.ht/site/downloads/Liste%20des%20 Institutions%20Sanitaires%202015.pdf. 173 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. 174 Andrew MacCalla. 2013. Training Skilled Birth Attendants in Haiti. DirectRelief. https://www.directrelief.org/2013/01/training-skilled-birth-at- tendants-haiti/. 175 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. 176 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. 177 Partners in Health. Haiti. https://www.pih.org/country/haiti?ms=lb. 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 L’Université d’État d’Haïti,” Family Medicine 50 (4), 259–61. doi: 10.22454/FamMed.2018.363441. 179 Health Finance & Governance Project. 2012. HFG Haiti Final Report. https://www.hfgproject.org/hfg-haiti-final-country-report/. 180 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. org/haiti-plan-strategique-de-developpement-des-ressources-hu- maines-pour-la-sante-2030/. 181 Health Finance & Governance Project. Haiti Health Workforce Data Audits to Human Resources for Health Improvements. https://www. hfgproject.org/health-workforce-data-audits-lead-improvements-hu- man-resources-health-haiti/. 182 Health Finance & Governance Project. 2012. HFG Haiti Final Report. https://www.hfgproject.org/hfg-haiti-final-country-report/. 183 Panamerican Health Organization. Health Information Systems. https:// www3.paho.org/ish/index.php/en/. 184 Ministère de L’Intérieur et des Collectivités Territoriales & Ministère de la Planification et de la Coopération Extreme, 2019, Plan National de Gestion des Risques de Desastre 2019-2030, République d’Haïti, https://www.undp.org/sites/g/files/zskgke326/files/migration/ht/Annexe- 3---PNGRD-2019-2030.pdf. 185 HaitiData. Webpage resource: https://haitidata.org/. 186 Lowrance DW, Tappero JW, Poncelet JL, Etienne C, Frieden TR, Delsoins D. Public Health Progress in Haiti. Am J Trop Med Hyg. 2017 Oct;97(4_Suppl):1-3. doi: 10.4269/ajtmh.17-0347. PMID: 29064358; PMCID: PMC5676629.. 187 Lowrance DW, Tappero JW, Poncelet JL, Etienne C, Frieden TR, Delsoins D. Public Health Progress in Haiti. Am J Trop Med Hyg. 2017 Oct;97(4_Suppl):1-3. doi: 10.4269/ajtmh.17-0347. PMID: 29064358; PMCID: PMC5676629.. 188 Health Finance & Governance Project. 2014. The Essential Package of Health Services and Health Benefit Plans in Haiti. https://pdf.usaid.gov/ pdf_docs/PA00MTRF.pdf. 189 Lowrance DW, Tappero JW, Poncelet JL, Etienne C, Frieden TR, Delsoins D. Public Health Progress in Haiti. Am J Trop Med Hyg. 2017 Oct;97(4_Suppl):1-3. doi: 10.4269/ajtmh.17-0347. PMID: 29064358; PMCID: PMC5676629.. 62 | Climate and Health Vulnerability Assessment: Haiti 190 United States Agency for International Development. 2020. Haiti Health Fact Sheet – January 2020. https://2017-2020.usaid.gov/ documents/1862/usaidhaiti-health-fact-sheet-january-2020. 191 Ken Hashimoto, Lauré Adrien & Sunil Rajkumar. 2020. Moving Towards Universal Health Coverage in Haiti, Health Systems & Reform, 6:1, DOI: 10.1080/23288604.2020.1719339. 192 Ken Hashimoto, Lauré Adrien & Sunil Rajkumar. 2020. Moving Towards Universal Health Coverage in Haiti, Health Systems & Reform, 6:1, DOI: 10.1080/23288604.2020.1719339. 193 Saria Hassan, Mytien Nguyen, Morgan Buchanan, Alyssa Grimshaw, Oswald P. Adams, Trevor Hassell, LaVerne Ragster, and Marcella Nunez-Smith, 2020, “Management Of Chronic Noncommunicable Diseases After Natural Disasters In The Caribbean: A Scoping Review,” Health Affairs 39 (12): 2136–43, doi: 10.1377/hlthaff.2020.01119. 194 Gouvernement de la République D’Haiti – Ministère de la Santé publique et de la population. 2015. Liste des Institutions Sanitaires du Pays. https://mspp.gouv.ht/site/downloads/Liste%20des%20 Institutions%20Sanitaires%202015.pdf. 195 Commune: a subdivision of a department. 196 Gouvernement de la République D’Haiti – Ministère de la Santé publique et de la population. 2018. Enquête Mortalité, Morbidité et Utilisation des Services EMMUS-VI, Port-au-Prince (Haiti): MSPP. 197 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. 198 Lia I. Losonczy, Sean L. Barnes, Shiping Liu, Sarah R. Williams, Michael T. McCurdy, Vivienne Lemos, Jerry Chandler et al., 2019, “Critical Care Capacity in Haiti: A Nationwide Cross-Sectional Survey,” PLOS ONE 14 (6): e0218141, doi: 10.1371/journal.pone.0218141. 199 Ministère de L’Intérieur et des Collectivités Territoriales & Ministère de la Planification et de la Coopération Extreme. 2019. Plan National de Gestion des Risques de Desastre 2019-2030, République d’Haïti, https://www.undp.org/sites/g/files/zskgke326/files/migration/ht/ An¬nexe-3---PNGRD-2019-2030.pdf. 200 Ministère de L’Intérieur et des Collectivités Territoriales & Ministère de la Planification et de la Coopération Extreme, 2019, Plan National de Gestion des Risques de Desastre 2019-2030, République d’Haïti, https://www.undp.org/sites/g/files/zskgke326/files/migration/ht/Annexe- 3---PNGRD-2019-2030.pdf. 201 Ministère de L’Intérieur et des Collectivités Territoriales & Ministère de la Planification et de la Coopération Extreme, 2019, Plan National de Gestion des Risques de Desastre 2019-2030, République d’Haïti, https://www.undp.org/sites/g/files/zskgke326/files/migration/ht/Annexe- 3---PNGRD-2019-2030.pdf. 202 United States Agency for International Development. 2020. Haiti Health Fact Sheet – January 2020. https://2017-2020.usaid.gov/ 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. 209 Kelly Sims Gallagher, Keston Perry, Mieke van der Wansem, Laura Kuhl, and Laurent Frapaise, 2019, Analysis of International Funding for Haiti’s Climate Change Priorities, Social Science Research Network, doi: 10.2139/ssrn.3333173. 210 Health Policy Project. 2016. Health Financing Profile: Haiti. https://www. healthpolicyproject.com/pubs/7887/Haiti_HFP.pdf. 211 Health Policy Project. 2016. Health Financing Profile: Haiti. https://www. healthpolicyproject.com/pubs/7887/Haiti_HFP.pdf. 212 Health Policy Project. 2016. Health Financing Profile: Haiti. https://www. healthpolicyproject.com/pubs/7887/Haiti_HFP.pdf. 213 Health Policy Project. 2016. Health Financing Profile: Haiti. https://www. healthpolicyproject.com/pubs/7887/Haiti_HFP.pdf. 214 Kelly Sims Gallagher, Keston Perry, Mieke van der Wansem, Laura Kuhl, and Laurent Frapaise, 2019, Analysis of International Funding for Haiti’s Climate Change Priorities, Social Science Research Network, doi: 10.2139/ssrn.3333173. 215 Gallagher, Kelly Sims and Perry, Keston K. and van der Wansem, Mieke and Kuhl, Laura and Frapaise, Laurent. 2019. Analysis of International Funding for Haiti’s Climate Change Priorities. Available at: https://ssrn. com/abstract=3333173 or http://dx.doi.org/10.2139/ssrn.3333173. 216 Gallagher, Kelly Sims and Perry, Keston K. and van der Wansem, Mieke and Kuhl, Laura and Frapaise, Laurent. 2019. Analysis of International Funding for Haiti’s Climate Change Priorities. Available at: https://ssrn. com/abstract=3333173 or http://dx.doi.org/10.2139/ssrn.3333173. 217 Gallagher, Kelly Sims and Perry, Keston K. and van der Wansem, Mieke and Kuhl, Laura and Frapaise, Laurent. 2019. Analysis of International Funding for Haiti’s Climate Change Priorities. Available at: https://ssrn. com/abstract=3333173 or http://dx.doi.org/10.2139/ssrn.3333173. 218 World Bank. 2020. World Bank Group Strategy for Fragility, Conflict, and Violence 2020-2025. https://documents1.worldbank.org/curated/ en/844591582815510521/pdf/World-Bank-Group-Strategy-for-Fragili- ty-Conflict-and-Violence-2020-2025.pdf. 219 Haiti - Environment and Global Climate Change - Country Dashboard - All (usaid.gov). Description of data —“Mortality rate attributed to household and ambient air pollution is the number of deaths attributable to the joint effects of household and ambient air pollution in a year per 100,000 population. The rates are age-standardized. Following diseases are taken into account: acute respiratory infections (estimated for all ages); cerebrovascular diseases in adults (estimated above 25 years); ischemic heart diseases in adults (estimated above 25 years); chronic obstructive pulmonary disease in adults (estimated above 25 years); and lung cancer in adults (estimated above 25 years).” 220 United States Agency for International Development. 2020. Haiti: Climate Risks to Resilience Food Security in Bureau for Humanitarian Assistance Geographies — Haiti, ReliefWeb, September 2020, https:// reliefweb.int/report/haiti/haiti-climate-risks-re¬silience-food-security-bu- reau-humanitarian-assistance-geographies. References | 63 64 | Climate and Health Vulnerability Assessment: Haiti MARCH 2024