Dr. Catherine Maternowska is an assistant professor at the University of California, San Francisco in the departments of Obstetrics, Gynecology and Reproductive Sciences and Anthropology, History and Social Medicine. She is currently conducting research in Tanzania. In a July telephone interview, she described observations of her work in Haiti over the last couple decades, and the increase in violence that she’s seen.

Did you come into contact with issues of violence against women when you were in Haiti?

I did see extreme amounts of violence against women. The peak of that was during what I called the “post-coup d’etat era” in my book, which was after Aristide’s first government was ousted in a coup d’etat and then it was replaced by a paramilitary and then military government, and then he was returned in 1994 — so between 1991 and 1994. So the central part of my fieldwork was also [at] the height of repression against women. And that was when everybody turned on everybody, basically.

And it started with military actions against women, raping and gang-raping a woman and asking mothers to, you know … the military pointing guns to sons’ heads and forcing sons to rape mothers, stuffing guns up mothers’ bodies and things like this. I didn’t actually observe anyone being raped during my fieldwork, but I recorded many cases of rape. And because I was one of the few people working in the community at that time, I needed to collect data and I was at that point in my life pretty much fearless. So I ended up continually going down in the morning and walking over dead bodies and collecting stories of rape and violence against men and women, but unconditionally more and more violence against women because of their gender status in Haiti. …

So, and levels of violence against women in Haiti have risen consistently since I’ve been working there in 1984, and they’ve gotten worse and worse. And I think there’s just a basic breakdown of society in Haiti, and that’s how it was explained to me both by men and by women. … The traditional protective factors in Haitian society and the norms, sort of cultural values have been unwoven by different economic programs and political upheavals that are just consistent and unending in Haiti.

The gender officer from Minustah told me there were much higher incidences of gang rape in Port-au-Prince recently. Is that something you’re familiar with?

Gang rapes are a common factor of the disintegration of any society. In Haiti, as I said … women’s rights have always been quite poor … so there’s nothing to protect them when something does happen to them. So yes, there are gang rapes, there are rapes going on inside homes, there’s women working in an economy that offers nothing else so survival sex is really important, and rapes are likely to happen every evening all over the town of Port-au-Prince.

I’d like to confirm that girls or women living without a male figure in their homes are more likely to be targeted.

Yes … that sort of arrangement is typical in the Caribbean where the female stays in the household with the kids, and although she may [have] children from many different men, there is usually one man that stays for some time and then moves on, so there’s serial monogamy. And it began with migration in Haiti, when men started leaving the countryside and tried to look for work elsewhere when the rural economy started breaking down in the mid-70s [and] USAID [U.S. Agency for International Development] tried to start industrialization and economic programs in the city. So that’s been an ongoing phenomenon for years and years and years.

So women are used to managing households, and I think it’s about 50 percent of all households in Haiti are managed by women, but at some point in time they usually have a man there to protect them … And so when women lose their partners altogether for whatever reason, …they do become vulnerable and everyone in the community is aware that they’re alone. That again increases their vulnerability to one more level of danger … I guess it was laid most bare to me during that post-coup d’etat era, because all the men left Cité Soleil. There were very few men left. It was just women, and that’s when the raping started — and the gang raping and military rapes and the civilian rapes against women.

How are PEPFAR [President’s Emergency Plan for AIDS Relief] prevention programs being received by the Haitian population you observed?

I think that abstinence is extremely culturally and contextually specific in each country, in the United States or elsewhere depending on what population and what age and what gender you’re working with … But in Haiti, I argue — and my arguments are based on testimony from Haitian men and women — that abstinence doesn’t work … primarily because of the economy. You know, when the economy is so poor and faltering so much, men and women are offered few options outside of sexual transactions. And so if sexual transactions are absolutely the only way to survive because there’s no other economic alternative, then abstaining is choosing death. And any person in the world, be it in Haiti or San Francisco, wouldn’t choose death as an option. So it simply doesn’t work. I understand the impetus for abstaining, because HIV and sexually transmitted infections and unwanted pregnancies are all huge health obstacles and problems and challenges in Haiti — and they have been ever since family planning programs first began in Haiti — but it’s not a solution. …You know girls are being drawn into sexual transactions at a younger and younger age in Haiti because their parents have died or because their parents are chronically ill with diseases … or simply [because of] hunger. And so girls are pushed into that market as viable economic assets at an earlier and earlier age, and therefore that makes abstaining absolutely impossible. When a girl can’t argue her rates, let alone say to her parents, “I’m now going to go sell my body so we can all eat,” I mean she can’t argue that, so she can’t argue for abstaining with her parents or with herself or really at all with the partner that she might be with.

If you could describe the location of USAID in Haiti …

… [A] lot of the people in USAID, they want to do well. But because they are never able to leave their offices due to the security conditions in Haiti, they’re never really able to see the reality. … [B]ecause of the physical definition between where people in policy and program positions sit versus the reality outside where they are supposed to be working, because of that physical separation they never really see what the reality is. And I think it’s a shame and a great loss to our investment in countries. … The key is getting people who are critical of the work to be accepted and have their voices heard so that policy can be improved.

There was a neighborhood that I visited that my translator told me was called “Kosovo.” Do you know that area?

Not that particular one, I have worked in different communities in Cité Soleil that were given names like that, which were names of big cities far away or conflict areas or zones. Haitians are incredibly … their distance from the new world is not that far, and yet … it’s arcane the way people live and very dehumanizing. And yet, Haitians are very aware of what’s going on in the world and always have a transistor radio to their ear. So when they hear about conflicts in areas around the world, they relate to them. They relate to them in very real ways, so that’s where the naming of the communities comes from.

I’d like to return to the idea of the role of economy in women’s choices about sex … for example, do women feel that they can refrain from having sex if their partner won’t wear a condom?

In the case of all the women I interviewed, no. …There are of course exceptions to this, and there are increasingly in some parts of the country really good health clinics that are really stressing gender roles and working with men and women. But in the case of Cité Soleil and during the years when I was working there and more recently when I was there in 2005, those rights overall have not changed. And women did not have the right to negotiate — partly because of their gender and who they are within the Haitian society and Haitian context, and partly because as men in Haiti have become more emasculated by the lack of opportunities … they’re no longer able to politically organize, they’re no longer able to find jobs. One of their last sources of power is through sexual transactions. And unfortunately, it often turns to violence because they’re frustrated as men or women would be without a livelihood. And so I think the combination of that frustration, and anger and hunger — I mean literally not having food — combined in a society where women have not traditionally had a lot of rights doesn’t give women the upper hand in decision making around sex.

Do you think there needs to be larger structural reforms in Tanzania?

It’s too early to say … Haiti’s proximity to the United States makes it quite vulnerable as a nation to U.S. pressures and policy pressures. And that stems towards the flow of refugees towards larger shores, so it’s a different confluence of events going on between Haiti and the United States and all the policies that go down in Haiti through the U.S. … Tanzania is farther away. Tanzania has a history of socialism. Tanzanians are not as likely to be on their knees as Haitians have typically been in a position of dependence on foreign aid. And there are a lot of American agencies here. I am part and parcel of that now as a researcher, as I was in Haiti trying to look at this issue and trying to discern what’s happening.

Can the Ministry of Health in Haiti make independent decisions?

… So, there is a huge amount of dependence [on U.S. aid] and I think even though the Haitian government has a very strong stance on issues around family planning and HIV-AIDS that might be very different than the U.S. they are not in a position to opine on those issues because they would run the risk of losing funding altogether. And not only in the health sector, but in other sectors.

Could you tell me a little about the general hospital in Port-au-Prince?

The general hospital is the state hospital which is attached to the medical school of the University of Haiti, and it is again ostensibly said to be the hospital for the majority poor and the urban poor. When women are bleeding or hemorrhaging, yes, they will go there; when someone is raped, yes, they may go there. But issues of going somewhere in Haiti are pretty complicated depending on the hour of the night, the danger of the context of going out to the street, actually having enough money for transportation to get to the hospital, then arriving in the hospital and having to pay for everything from cotton swabs to syringes to medications and food and providing food for the patient that’s in the hospital. And then, if the hospital itself is not on strike with the staff, it’s just sort of a non-stop series of variables…

There’s a hospital and there are poor that are supposed to use that hospital, but it’s such a complicated situation in Haiti again — structurally, politically, economically — that it makes it difficult to actually access health care even if it is there. And the last time I was there the morgue was overfilling … the nurse and I, when we were speaking, were covering our noses with handkerchiefs to keep the stench out … because it was overflowing with bodies. And the maternity ward where I was working was extremely underdeveloped, and lots of women were moaning in their beds. I mean the situation was deplorable in that hospital, the infrastructure is deplorable.

There are solutions to this, [such as] the private and public sector working together. And in cases where people have used public sector infrastructure and private sector workforce and public sector workforce together — [as] I think Paul Farmer has done in various parts of the Central Plateau — that sort of model works. And they did the same thing at the Albert Schwietzer hospital, they used a mixed model. That can work and that can make health care possible and potentially an accessible thing for the majority poor in Haiti. But as it stands now, the general hospital does not function very well.

Could you tell me a little bit about the role of consultants in Haiti?

The consultants that I dealt with saw very little of the communities they were working in. That was partly a reflection of the agencies and institutions that hired them. I mean, if they had seen the reality, then why would they send their consultants in necessarily to see the reality? Which is why I was one of very few that would get hired to work in Cité Soleil … That’s typically the case, and I think where people do do visits, they go out for one day, but they’re not seeing the ramifications of what goes on in a setting, in a village that has a small health care dispensary. It’s rock bottom. And if you go out to the countryside, you’ll see it’s very difficult to survive in Haiti and it’s uncomfortable — it’s not a hotel. And as far as I’ve seen, it’s far worse than most places in Africa that I’ve ever been.

Consultants, even if they are paid high dollars, they don’t really want to go and stay there. They say they’ve seen it before and they know what it is. But it’s a complicated place, Haiti, as are all countries. Often people who go into communities miss the underlying messages of what’s going on.

Note: This interview was edited for length and relevance.