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Port-au-Prince

December 1994 THE FLIGHT FROM MIAMI to Port-au-Prince is only an hour and 20 minutes. As we taxied down the runway, preparing for takeoff, I began reading Internet reports about Haiti and its problems. Haiti, once the richest colony in the French empire, is now the poorest nation in the Western Hemisphere. Founded after the world’s only successful slave rebellion, it only recently became democratic. The reports made for grim reading: average income, $175 per year; life expectancy, 57 years; 75 percent illiteracy rate; and extraordinarily high death rates from diarrhea, tuberculosis, and malaria—all treatable diseases. I lifted my head from a report, looked out the window, and saw that we were already over Haiti. It was a day so clear that even from 30,000 feet, I could make out trees and huts on the land below. Haiti is a mountainous country, and the deforestation described in one of the reports is painfully apparent as you approach Port-au-Prince from the air. The capital city sits in a valley between two mountain ranges next to the mouth of a river. The gray of the city contrasts with the green and brown of the mountains and the blue of the Caribbean Sea. Despite the deforestation, my first impression was that of a rugged but beautiful land.



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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Port-au-Prince December 1994 THE FLIGHT FROM MIAMI to Port-au-Prince is only an hour and 20 minutes. As we taxied down the runway, preparing for takeoff, I began reading Internet reports about Haiti and its problems. Haiti, once the richest colony in the French empire, is now the poorest nation in the Western Hemisphere. Founded after the world’s only successful slave rebellion, it only recently became democratic. The reports made for grim reading: average income, $175 per year; life expectancy, 57 years; 75 percent illiteracy rate; and extraordinarily high death rates from diarrhea, tuberculosis, and malaria—all treatable diseases. I lifted my head from a report, looked out the window, and saw that we were already over Haiti. It was a day so clear that even from 30,000 feet, I could make out trees and huts on the land below. Haiti is a mountainous country, and the deforestation described in one of the reports is painfully apparent as you approach Port-au-Prince from the air. The capital city sits in a valley between two mountain ranges next to the mouth of a river. The gray of the city contrasts with the green and brown of the mountains and the blue of the Caribbean Sea. Despite the deforestation, my first impression was that of a rugged but beautiful land.

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti At Barth’s request I had recruited a team to visit Haiti to see the situation firsthand and assess what we might do. The team consisted of 23 doctors and nurses, most of them faculty members at the University of Miami. In addition to Barth and myself, the doctors in the group included Lynn, chair of family medicine; Michel and Henri, two Haitian-American faculty members also from family medicine; Ron, the Haitian-American director of our radiology residency program; and Jackie, University of Miami alumna who directed Miami’s public health department. On the nursing side, Diane, dean of the University’s school of nursing, and Lydia, one of her faculty members, were interested in international nursing from an academic perspective. Their scholarly approach to the problems faced by Haiti’s nurses was balanced by the practicality of Ruth, the head nurse of Miami’s homeless clinic. Junia, my assistant, and some photo and video journalists Barth had recruited from the Miami Herald and our local Channel 10 rounded out the group. During the flight down, Danny T. visited each row of members of our group and gave instructions: “Stay together. Pay no attention to requests to take your bags, even if someone looks like they are in some kind of uniform. And above all, don’t submit to the temptation of giving something to people begging, especially the children. It will start in the airport parking lot, and if you give to one, you will have to give to everyone. Then you will have nothing left. Be prepared for an assault on your senses. Haiti is a land of contrasts.” As we flared over the runway, rows of U.S. Army helicopters came into view, along with groups of U.S. soldiers and their equipment. “It looks like we are flying into a war zone,” someone murmured. We exited the plane and descended the portable ramp to the tarmac. We were immediately hit by a blast of heat and wind. The trade winds spilled over the mountains to the east and rolled across a broad plain toward the Bay of Port-au-Prince. Impressive mountain

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti ranges rimmed the plain to the north and the south. A small konpa band played as we entered the terminal. Following Danny’s advice, we got through customs and baggage claim swiftly. Danny T. was right. The begging started in the airport parking lot, as we loaded into the Pajeros that would take us to our hotel. Each of the four small trucks was surrounded by 10 to 20 children, mostly boys, ages ranging in age from 8 to 14. In English we heard, “You got money for me?” “You help me, mister?” “Quarters?” “Dollar?” These pleas were made softly and frequently with a smile. Our driver responded harshly in Creole but without deterrent effect. We finally began to drive off, with children clutching our open windows, half of them running and half being dragged along with us. The assault on our senses had begun. The air was filled with the acrid stench of burning garbage. As we proceeded from the airport to the center of Port-au-Prince, we could see piles of uncollected trash smoldering by the side of the road. Some of these heaps were taller than I was. Some covered a half acre. Their blue smoke, mingled with the dust blowing off the naked hillsides, stung our eyes and obscured the clear blue sky we had seen from the airplane. Even in the capital, goats were nibbling on trash, live chickens hung by their feet in open-air markets, and burros were used as beasts of burden. For that matter, so were humans. Small men pulling two-wheeled carts piled high with boxes were everywhere. Women carried water, food, or bread on their heads. We passed a military checkpoint on the way downtown. With that one exception, we saw no sign of law, nor any sign of disorder. The narrow streets were crowded with people. In fact, it seemed as if the entire city lived in the streets. Automobile traffic was heavy and slowed by the crush of people. However, a gentle toot of the horn and pedestrians immediately yielded the right-of-way to the automobiles. There were no traffic lights working, but our drivers were skilled with their horns as they approached intersections or corners and were careful to negoti-

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti ate the seemingly endless series of potholes, puddles, and ruts. If we stopped our minicaravan, children appeared from the crowd and asked for money. They were gently discouraged by our drivers. For the most part, though, we were ignored. How strange for such a poor country to have so much industry in its streets, I mused. People were weaving hats and baskets from palm fronds, making rattan furniture, and refurbishing old box springs, all out on the streets. Brilliantly colored paintings hung from walls and fences. “A nation of artists,” Henri volunteered, “but who’s going to buy their works?” Most of the traffic consisted of large trucks carrying construction materials or “tap-taps,” Haiti’s form of public transportation. Tap-taps (named for the sound made by their engines running) ranged from small pickups outfitted with a carved wooden “bonnet,” through buses, to 12-wheelers. For a few gourdes one could travel all around the city on the smaller pickups or, for a few gourdes more, all the way to Cap Haitien or Jérémie. The larger tap-taps have their route painted on the side, front, and back. Both small and large are decorated with bright colors, paintings, designs, and frequently hand-carved wood trim. They also have elegantly painted religious phrases or pawòl granmoun, expressions of folk wisdom. Most spewed out diesel smoke that mingled with the smoke from the piles of burning garbage we encountered every few blocks, to sting our eyes and make us pinch our nostrils. It seems there had been no trash pickup during the three years of the embargo, and people burned their garbage with gasoline or kerosene when the piles became insurmountable obstacles. The color of the streets varied from drab concrete gray to explosions of bright colors, particularly around the open-air markets, with a seeming abundance of squash and vegetables accented by the white feathers and red combs of the upside-down chickens. Everyone (in most places the sidewalks were five to six people deep) seemed to have some place to go or something to do. Toothless old people

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti mingled with groups of school children in uniforms, walking as a group with knapsacks on their backs. We stopped at the Holiday Inn before going to the university hospital. In the back of the hotel was a courtyard, a tropical garden with shade, a breeze, and leaves that seemed to soak up the haze, dust, and diesel smoke. Those of us who were in Haiti for the first time shared our initial impressions. For our Haitian-American faculty, it was the beginning of a four-day reunion. Some had not been home for more than a decade, and all had not been able to return home during the three years of the embargo. Every new face in the hotel came over and introduced himself or herself, followed by smiles and embraces. Marlon and Jerry rejoined us. They would be inseparable from us over the next four days. They were in their element now. Any shyness that had afflicted them in Miami had melted away in their own country. They were ecstatic that we had come and hopeful that we could help them and their people, even if that prospect for help was in the distant future. They were classic twin brothers. One started a sentence and the other finished it. Their English was excellent when they were fresh, but when they were tired they sometimes struggled for words. They were kind enough to use English, since most of our group did not speak French or Creole. They carried small radio phones, which were constantly ringing, and they had the uncanny ability to carry on one conversation concerning patient care in Creole with each other while speaking to us in English. Their energy was boundless and their dedication obvious. Several times over the next four days, one or both would excuse themselves “for just a brief emergency surgery.” Then they would disappear for 20 minutes to half an hour and then reappear and resume the tour. At the same time, they had the kind of surgical irreverence that made “M*A*S*H*” so humorous. They wanted to take us on a tour of the university hospital before the officially planned tour the following morning. As we

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti passed by a nursing class, several students waved, called their names, and blew kisses. The university hospital had been built by the U.S. Marines during their occupation in the first half of the 20th century. It reminded me of the hospital in which I had done my residency two decades ago—a complex of two- and three-story buildings with barrel-tile roofs and open-air porches. Across the street from the entrance to the hospital was a collection of drugstores, mortuaries, and coffin makers. As we were entering the emergency area, we passed two older Toyota vans with red crosses painted on their sides. One had its hood raised, and the other had a flat tire. “Our ambulance fleet,” commented Marlon dryly. Between the two defunct ambulances and the small door labeled “Emergency” was a tap-tap with two legs dangling outside. The woman inside had had a seizure and had yet to regain consciousness. She was being tended to by her fellow passengers. We entered a dark corridor. The walls were painted a dingy olive drab, and the stale smell of urine permeated the air. “This is the ER stabilization area.” The room we were in had several small cubicles. In one a resident was quietly suturing a laceration. In another cubicle a two-day-old baby with a colectomy was nestled in a crib with his mother at his side. Jerry explained that the baby was born with an imperforate anus. He and his brother had performed a colostomy to save the baby’s life. We proceeded through a maze of dimly lit corridors and passageways connecting one ward to the next. Each ward contained 20 to 30 beds. They were divided according to services—medicine, orthopedics, surgery, pediatrics, obstetrics. Each ward had more patients than there were beds. On most wards this meant that patients were doubled-up, two per bed. In the orthopedics ward, though, because of traction and other hardware requirements, there was only one patient per bed. The mattresses on the beds were old and stained, and there were rarely sheets. There were no nurses, no toilets, no running water, and no medicines. Marlon explained that if they

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti wanted a patient to have medicine, they had to write the patient a prescription, and either the patient or a family member would have to take it to a pharmacy across the street and return with the medicine to the hospital. At that point the patients were responsible for taking it themselves. Food and nursing care were provided by families. Those patients without families depended on passersby or fellow patients. Flies were everywhere in the surgical ward, where burn victims were recuperating. Burns are common in Haiti, where most people cook over open fires. Children frequently burn themselves when they pull over pots of food suspended over the fires by tripods. The burn victims avoided the flies by sleeping under mosquito netting. There were probably six or seven burn victims there that day, their dark uninjured skin in sharp contrast to the pink, yellow, and mottled burned tissue. Flies buzzed around a container filled with antiseptic solution. Jerry described how, without a sterilizer, unsterile gauze pads were dipped into the antiseptic solution to pack the wounds of surgical patients. Eighty percent of the emergency surgical patients developed sepsis, and 60 percent died. Many patients seemed to be there because they had no place else to go. Their doctors could figure out they had terrible maladies but lacked medicines to treat them. One woman with a tumor growing out of her skull had been waiting five months for surgery. James, a young boy with a beautiful smile, skated down the corridor on tin cans strapped to his knees. His legs were permanently folded at the knees by scarring that had developed after severe burns. He had been waiting two years for surgery, living at the hospital the entire time. There were some patients who were young but gaunt. These patients must have AIDS, I thought to myself. No one mentioned them or their problems, however. In fact, our Haitian hosts seemed to ignore them. Our next stop was an orphanage in a place called Post Cazeau, a complex of newer buildings on a large plot of land, near the airport. We could see planes taking off and landing just beyond the treetops. Marlon and Jerry said they would like to build a new hospital in a

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti vacant field next to the orphanage some day. Miriam, the director, volunteered that she would donate the land. She also had land out in the countryside, in a village called Pestel, that she would donate to Project Medishare. Miriam trained as a nurse and has been doing missionary work in Haiti for 23 years. She and Marlon and Jerry formed a “mutual admiration society.” In addition to running the orphanage, her organization, World Harvest, sponsors open-air clinics in villages in the countryside. “As bad as things are in Port-au-Prince, they’re 10 times worse in the countryside,” she informed us. “When we hold one of our clinics, 200 to 300 people will come from all around. Children with malnutrition and typhoid fever, people with tuberculosis and malaria. In Pestel there are 60,000 people in the surrounding area and not one doctor. The government has a building there, but there’s no one to staff it. We’re so pleased you’re going to help.” Marlon and Jerry pulled off a minor miracle by inviting the minister of health, the president of the International Red Cross in Haiti, the director of the university hospital, the dean of the medical school, and several other important people in Haitian health care to meet us at Post Cazeau. We later learned that our visit was the first occasion that brought all these dignitaries together in one place and time. In retrospect, however, I must admit this diplomatic miracle did not lead to long-term results. Miriam, her staff, and the orphans set up tables in a field next to the orphanage, under a canopy of palm fronds to provide needed shade. Our Haitian hosts were in agreement with regard to their priorities. First, the university hospital needed to be resuscitated as a teaching hospital. Then it needed to train doctors and nurse practitioners who could provide general medical care. Finally, there needed to be a coordinated system for transportation around the country and a way to maintain medical equipment and supplies. Project Medishare, representing, at least in the Haitians’ eyes, the University of Miami School of Medicine, could help in all areas—by

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti donating medical equipment and supplies, by developing the training that was needed, and, of course, by raising money. As a group of teenagers played homemade instruments and sang Haitian folk songs under a tree the entire afternoon, Miriam provided lunch and a tour of the orphanage. The orphans sang songs and presented Barth with a bouquet of flowers in honor of our visit. Miriam told us the story of each orphan in the chorus. Most were survivors of the wreck of the Neptune, a ferry boat from Jérémie that capsized during a storm. While the incident received fleeting coverage in the American press, it had become legendary in Haiti. Every street artist had a painting of the wreck of the Neptune, full of visual imagery of drowning innocents. The children, some 60 all told, were well behaved and affectionate. They made friends with each and every member of the group. Miriam told us that each one was hoping for adoption. Most of the faculty completed the tour with a child holding on to each hand. I had been warned by some Haitian friends in Miami to beware of the missionaries. Many missionaries are seen by the Haitian people as agents of the Central Intelligence Agency, and some missionaries have come to Haiti with pejorative attitudes about Voodoo or the Haitian work ethic. Much of the ceremony at the orphanage would have struck a cynic or skeptic as a calculated play for sympathy, but I felt skepticism draining from me in the face of such obvious need. In the course of our meetings, Miriam agreed to take six babies who had been abandoned at the university hospital. Without good nursing care, these children rarely survived long in the hospital. Any thoughts on my part that Miriam might be grandstanding were washed away by the heartfelt gratitude of the Haitian hospital officials, for whom the abandoned babies represented a huge problem. We reentered our Pajeros and snaked slowly in silence up the hill to Petionville, where our hotel was located. Although it was late at night, the life in the streets still pulsed. Although Petionville is considered a well-to-do suburb, there were people begging on the street

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti outside our hotel. Parked immediately next to the hotel was an abandoned hulk of a burned-out car, with five children living in it. Several members of our team kept bringing food from our meals out to the children. The hotel itself, built in Caribbean gingerbread style during a brief surge in tourism in the 1970s, was an oasis of comfort and service. This only served to further subdue the group. Some were too emotionally moved after the experiences of the day to enjoy the hotel’s hospitality. Others went directly to the bar. One doesn’t have to spend a long time in Haiti to realize that social class is a huge issue. I had read about this unique part of Haiti’s history as I prepared for our trip. The French plantation owners of Saint Dominique were true aristocrats—counts and marquises—but only French men were willing to give up the luxuries of France and endure the hardships and risks of the tropics. So they took slaves as concubines. The progeny of these liaisons were treated by their fathers as a special class. They weren’t free, but their fathers acknowledged their paternity and allowed them to own land, receive an education, and manage the plantations. So the Haitian revolution was really two revolutions rolled into one—a slave uprising by Africans, taking advantage of the chaos created by the French revolution to win their freedom, and an Oedipal revolt by the lighter-skinned mulattes. Both classes joined forces to drive out the French. Shortly thereafter, however, conflicting visions of who owned the country erupted into civil war. The result was a stalemate, with the Africans and their descendants controlling the land in the countryside and the mullates controlling the institutions—government, church, and education. The mulattes became, in effect, an unlanded aristocracy. Class politics became an endless cycle of power plays, oppression, and revenge. These class tensions have dominated the history of Haiti since the revolution—one class believing that Haiti is their birthright, the other that only they have the knowledge and skills to manage the country. Each is simultaneously dependent on and suspicious of the other. These tensions were readily apparent at the bar at the Kinam

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Hotel. The staff, coal black, talked among themselves in Creole but responded to their patrons in French. The bar clientele were all light-skinned, fashionably dressed, and insistent on impeccable service. Their eloquent Parisian French shamed my French-Canadian patois. I pulled Michel, one of my Haitian-American colleagues, aside to a quiet corner and asked him, “What’s the attitude of the elite toward the poor here?” Michel himself is a very light-skinned Haitian but more of a member of the intellectual elite rather than the economic elite. He traced part of his ancestry to French Huguenots from Nantes, and in truth the only hint of Black Africa in his features is the black curliness of his hair. He showed me on a map of Haiti where the plantation bearing his ancestral name was located. However, Michel was the rare individual with the ability to step outside class and take a truly objective view. He thought for a while before he responded. “I’d have to say there’s a spectrum of attitudes that range from ‘noblesse oblige’ to ‘let them eat cake.’ You can live well in Haiti, even if you’re not particularly rich, if you come from the right family. The poor provide servants—cooks, maids, and chauffeurs. Some are treated as members of the family; others are frankly abused. I’ve always found it ironic that a country born of the only successful slave revolt in the world has so many of its people working as servants. For them it’s almost like the revolution never happened. For the most part, however, most of the elite are ignorant of the plight of the poor. They’re isolated from the problem. They never leave the capital.” “The gulf between the rich and poor is pretty glaring,” I remarked. “The houses on the crest of the hill above the hotel are as impressive as anything in Miami and with a much better view. Isn’t it a little ironic that we’re down here trying to help and some of the elite could care less?” I asked. “It’s not that simple, Art,” Michel responded. “Some do care. Charity is different here, however. A family might quietly support a poor family they know or one particular orphanage. Occasionally, a prominent family will adopt a cause like a hospital or an orphanage.

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Most of the doctors are sons or daughters of the elite, and all of us give back to a greater or lesser extent. Look at Marlon and Jerry. The thing is, you’re seeing all this with the eyes of an American. I wonder really if it’s all that different in the United States, except there’s more wealth and less poverty there. But take everything we’ve talked about with regard to ‘class’ and substitute ‘race,’ and that’s what you’ve got in the States. How many white Americans feel any responsibility or sense any connectedness to black Americans?”