Dr. Philp McMillan,  John McMillan

“”What if we studied success stories as intently as we study vaccines?”

837 is a number that should have stopped the world’s epidemiologists in their tracks. That’s the total COVID-19 death toll Haiti reported out of 11.4 million people, with only 2.7% of its population vaccinated. To put this in perspective, that’s roughly 7 deaths per 100,000 people over the entire pandemic. The United States, with its advanced healthcare system and high vaccination rates, recorded over 300 deaths per 100,000. Something extraordinary occured in Haiti, and the global health community barely noticed.

Dr. Patrick Daly has unique insights into what happened. As Haiti’s former Director of Epidemiology, Laboratory, and Research from 2018 to 2022, he orchestrated the country’s COVID response from day one. “I was the first person who managed all data in for the country,” he explains in a recent interview, his accented English conveying the tone of someone who’s seen his nation’s achievements dismissed all too often.

Daly didn’t just collect data; he helped shape a strategy that achieved what may be among the world’s most remarkable pandemic outcomes. “Our expectation was… more than 60,000 deaths,” he reveals. Instead, they lost fewer than a thousand souls.

The devastating earthquake of 2010 forced Haiti to rebuild its public health infrastructure from the ground up. With financial support from Western institutions and the World Bank, Haiti constructed a surveillance network of over 1,000 offices, with 85% reporting in real-time through electronic systems. This operation was sophisticated enough to track not just COVID, but any unusual spike in deaths across the country, even in rural outposts.

When whispers of a new virus emerged from China in late 2019, Daly and his team began working overtime. Before the WHO made an announcement, before most countries even acknowledged the threat of a deadly airborne virus, Haiti had already begun monitoring respiratory infections. They blocked flights. They prepared. “We were the first. In all decisions,” Daly recalls. By the time Haiti recorded its first case, they’d already been watching and waiting for three months.

Echoes of an Old Paradox

To understand why studing the Hatian COVID response is important, we need to travel back to the 1950s, when polio terrorized American families. In 1952 alone, the virus paralyzed over 21,000 children in the United States. Parents kept their kids away from swimming pools, movie theaters, anywhere the invisible enemy might lurk. Cities emptied and iron lungs filled hospital wards.

Meanwhile, in countries Americans considered less developed, children played in unsanitized streets, seemingly untouched by an epidemic that had brought the developed world to its knees.

To their credit, epidemiologists at that time took notice. The explanation, when it came, turned conventional wisdom upside down. In less sanitized environments, infants encountered poliovirus early and often, usually while still protected by maternal antibodies. These early infections were mild, often unnoticed, but they conferred lifelong immunity. In cleaner, more developed nations, children encountered the virus later, when it could invade the nervous system with catastrophic results.

Better hygiene had created a paradox: it protected children from early, harmless exposure, leaving them vulnerable to severe disease later.

Could something similar explain Haiti’s COVID outcomes? The evidence suggests it might. Haiti’s population lives with constant exposure to pathogens that would overwhelm Western immune systems. Dengue fever, which can be devastating elsewhere, often presents mildly in Haiti; indeed, it is so mild that Daly notes they see fewer hemorrhagic cases than the neighboring Dominican Republic, despite similar mosquito populations.

Haitian immune systems seem to have learnt a different language, one that communicates fluently with familiar threats and knows how to negotiate better with novel ones.

“Cross-immunity,” Daly calls it, though he’s quick to add they need more funding to study it properly. The concept isn’t far-fetched. Recent research shows that exposure to common cold coronaviruses can generate T cells that recognize SARS-CoV-2. In a population constantly challenged by diverse pathogens, these cross-reactive immune responses might be more robust, more nuanced and seasoned, like a cast-iron skillet that gets better with use.

The Demographic Shield

But immunity tells only part of the story. Haiti’s population pyramid looks nothing like those of wealthy nations: 60% are under 24 years old. This is a consequence of a healthcare system that, as Daly puts it with brutal honesty, doesn’t allow people with serious chronic diseases to “exist really” into old age.

Ironically, Haiti’s lackluster healthcare infrastructure created an unintended shield: fewer elderly people with managed comorbidities meant fewer vulnerable targets for COVID to attack.

It’s worth noting that Haiti wasn’t alone in this pattern. Several African nations with young populations and limited healthcare infrastructure also reported lower-than-expected COVID mortality, suggesting demographic composition plays an important role in pandemic outcomes.

The environment played its part too. “The majority of Haitians spend their time outside in the open air, in the sunshine,” Daly observes. While Americans retreated indoors, where the virus spreads efficiently, Haitians continued their largely outdoor lives. Their traditional diet, what Daly calls “bio… very organic and biological,” may have contributed too, though how much remains unmeasured.

When illness did strike, Haitians often turned to traditional remedies: thyme, cloves, and other preparations passed down through generations. These weren’t validated in clinical trials, but they kept people calm, at home, and away from hospitals unless truly necessary. The community had its own ways of managing respiratory illness, refined over centuries.

The Vaccine That Wasn’t

Perhaps most remarkably, Haiti achieved these outcomes while taking a different path from the global consensus. “Most of the population didn’t believe in vaccines,” Daly admits. Even healthcare workers refused them, viewing the whole pandemic response as “a political game.” Only when deaths began appearing did some accept that COVID was real, but by then, the wave had largely passed.

This skepticism, born from decades of international interventions that promised much and delivered little, accidentally aligned with Haiti’s natural advantages. While wealthy nations achieved high vaccination rates but still struggled with waves of disease, Haiti’s 2.7% vaccination rate became a footnote to one of the pandemic’s most successful outcomes. This suggests that pandemic responses need to account for local contexts and existing protective factors.

Lessons Unlearned

“We got a congratulatory letter,” Daly mentions, almost as an afterthought. The WHO acknowledged Haiti’s exceptional surveillance work. Then… nothing. No teams of researchers descended to study their methods. No funding materialized to investigate why their outcomes defied predictions. The world moved on, leaving what might be the pandemic’s most important natural experiment unexplored.

The tragedy isn’t just scientific; it’s human. Here was a nation that did almost everything differently from global recommendations: minimal vaccination, traditional medicine, limited hospital capacity. Yet they emerged with outcomes that should be the envy of the world.

“I was sleeping only one or two hours a day,” Daly remembers of those frantic early months, his team working around the clock to protect their country. They succeeded beyond anyone’s wildest expectations, only to be overlooked.

The reasons for this oversight aren’t hard to fathom. Haiti’s success didn’t fit the prevailing zeitgeist. It suggested that expensive interventions might matter less than population structure, environmental factors, and early exposure patterns. It implied that understanding local context might be more important than imposing universal solutions. Most uncomfortably, it showed that different approaches could yield superior results.

A Call for Humility

Haiti’s COVID paradox raises important questions about pandemic preparedness and response. What if our focus on pharmaceutical interventions, while crucial, has overshadowed other protective factors? What if resources could be allocated more effectively by understanding why some populations show natural resilience? What if Haiti’s outcomes had been studied with the same intensity as vaccine trials?

These questions don’t negate the importance of modern medicine. Instead, they suggest that our understanding of pandemic dynamics could benefit from greater nuance and humility. Different populations face different risks and possess different strengths. A one-size-fits-all approach may miss opportunities to save lives.

Haiti’s experience demonstrates that local knowledge, environmental factors, and population dynamics can intersect to create remarkable outcomes. The infrastructure exists to study this properly. Haiti’s modern surveillance system could yield insights that might inform approaches to future pandemics. All that is required is funding and respect.

“Anytime you need some information, I’m here,” Daly offers at the end of his interview. It’s a generous invitation from someone whose expertise the world has largely overlooked.

In the end, Haiti’s COVID miracle isn’t really a paradox at all. It’s what happens when smart leadership meets local knowledge, when surveillance systems work properly, and when populations carry immunological memories we’ve forgotten exist. Their outcomes weren’t luck; they were the logical result of factors we’ve barely begun to understand.

Perhaps it’s time we took Daly up on his offer. The next pandemic is coming, and Haiti’s lessons might help us face it better, if we’re humble enough to learn.

Substack Interview: Why Did Haiti Have the Lowest COVID Death Rate? My Conversation with a Lead Epidemiologist