title: Haiti's food and drinking water: a review of toxicological health risks.
abstract: BACKGROUND
  The Republic of Haiti is a developing country in the Caribbean region with a history that challenges toxicologists, yet the historical panoply of toxicological hazards in Haiti has received little scholarly attention.
  
  
  OBJECTIVE
  The primary objectives of this paper are to review what is known about Haiti's current toxicological hazards, with a focus on chronic food-borne aflatoxin exposure and heavy metal contamination of water resources, and to compare these with previous large-scale, acute exposures to toxic substances: the 1995-1996 diethylene glycol (DEG) intoxications and the 2000-2001 ackee fruit poisonings.
  
  
  METHODS
  MEDLINE/PUBMED and the library website of Cornell University were searched using the terms "Haiti" and either "heavy metals," "aflatoxin", "diethylene glycol", or "ackee". The search was inclusive of articles from 1950 to 2012, and 15 out of the 37 returned were peer-reviewed articles offering original data or comprehensive discussion. One peer-reviewed article in press, two newspaper articles, two personal communications, and one book chapter from the personal databases of the authors were also referenced, making a total of 21 citations.
  
  
  RESULTS
  Elevated concentrations of aflatoxins (greater than 20 μg/kg) were documented for staples of the Haitian food supply, most notably peanut butters and maize. Human exposure to aflatoxin was confirmed with analysis of aflatoxin blood biomarkers. The implications of aflatoxin exposure were reviewed in the light of Haiti's age-adjusted liver cancer risk - the highest in the Caribbean region. Measurement of heavy metals in Port-au-Prince ground water showed contamination of lead and chromium in excess of the US Environmental Protection Agency's 15 μg/L Action Level for lead and 100 μg/L Maximum Contamination Level Goal for total chromium. The DEG contamination of paracetamol (acetaminophen) containing products in 1995-1996 claimed the lives of 109 children and the 2000-2001 epidemic of ackee fruit poisoning resulted in 60 cases of intoxication. Lessons for the Haitian Government. The DEG and ackee epidemics overwhelmed local Haitian public health resources. Yet, periods of 8 and 4 months, respectively, passed before the Haitian government sought assistance following the initial poisonings. To our knowledge, the Haitian government did not enact policy to promote drug safety and prevent future poisonings. This will not likely change in the near future because of the state's finance and personnel crises. While protection of its people remains the prerogative of the Haitian government, it is extremely limited in managing chemical exposure to environmental toxins, including aflatoxin and heavy metals.
  
  
  CONCLUSIONS
  The cases of DEG and ackee fruit poisoning demonstrate that environmental exposures to chemicals have occurred in Haiti. Current low-level exposures to aflatoxin and heavy metals highlight the risk that large-scale poisonings can occur. While awareness of toxicological hazards in Haiti must be acknowledged more widely within the government and non-governmental sectors, the lessons of these exposures are relevant to all developing countries where the capacity to discern and manage toxicological risks is absent or not yet effective.
authors.affiliation: Institute for Comparative and Environmental Toxicology, Cornell University , Ithaca, NY , USA.
authors.forename: J R
authors.initials: JR
authors.lastname: Schwartzbord
authors.forename: E
authors.initials: E
authors.lastname: Emmanuel
authors.forename: D L
authors.initials: DL
authors.lastname: Brown
mesh_terms: D003906:Developing Countries; D054750:Ecotoxicology / Q000331:legislation & jurisprudence; D063427:Food Quality; D005523:Food Supply / Q000331:legislation & jurisprudence; D006205:Haiti; D006304:Health Status; D006801:Humans; D012307:Risk Factors; D060753:Water Quality; D014881:Water Supply / Q000331:legislation & jurisprudence