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Cité Soleil

THE FOLLOWING MORNING WE returned to the university hospital for the official visit. I spoke with our Haitian-American faculty as we assembled outside prior to the tour. All three were stunned by what they had seen the previous day. “Haiti always was a poor country, but the health care system worked,” said Michel. “I trained here in medicine. I had a good experience. Now, there is nothing left. It’s like a shell.”

“I went by the radiology department yesterday,” added Ron, who ran our radiology residency program, “and none of the machines are working. I can’t tell you how much things have deteriorated.”

“What happened?” I asked.

“Number one is the embargo. Remember, while humanitarian supplies were allowed in, things like mattresses and sheets didn’t count. Also, under the embargo, the price of everything went up, which promoted theft. Things could always be sold on the black market. Second, politics influences everything in Haiti. Under the military government, all appointments were political. People could just go to the ministry of finance and pick up their paycheck and then go to their real job. There was no accountability. Finally, in the days just prior to the U.S. intervention, there was the revenge factor.



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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Cité Soleil THE FOLLOWING MORNING WE returned to the university hospital for the official visit. I spoke with our Haitian-American faculty as we assembled outside prior to the tour. All three were stunned by what they had seen the previous day. “Haiti always was a poor country, but the health care system worked,” said Michel. “I trained here in medicine. I had a good experience. Now, there is nothing left. It’s like a shell.” “I went by the radiology department yesterday,” added Ron, who ran our radiology residency program, “and none of the machines are working. I can’t tell you how much things have deteriorated.” “What happened?” I asked. “Number one is the embargo. Remember, while humanitarian supplies were allowed in, things like mattresses and sheets didn’t count. Also, under the embargo, the price of everything went up, which promoted theft. Things could always be sold on the black market. Second, politics influences everything in Haiti. Under the military government, all appointments were political. People could just go to the ministry of finance and pick up their paycheck and then go to their real job. There was no accountability. Finally, in the days just prior to the U.S. intervention, there was the revenge factor.

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti The military was not about to leave anything of value to the Aristide government, so they took what they could and trashed the rest.” We entered the building and were led to the office of the newly appointed director of the hospital, where we also met with several members of the faculty and medical staff. The director was quite candid. “We have nothing!” After introductions in English and French, and a brief statement from each of us as to what we hoped to accomplish, we embarked on the tour. To Marlon and Jerry’s surprise, with the exception of the presence of one or two nursing student volunteers on some of the wards, the official tour showed us pretty much the same conditions as we had seen the day before. After the tour, our caravan weaved through the pedestrian traffic from the center of Port-au-Prince to St. Catherine’s Hospital in Cité Soleil. “Cité Soleil is the lowest point in the city,” Dale, our driver explained. “It was where they unloaded the slaves in colonial days. During the Papa Doc years, they changed the name to Cité Simone, in honor of his wife. They resettled people from the countryside during those years. It was never intended to be permanent. Now, there are people who have lived their entire lives there.” The neighborhoods we passed through were clearly poor, with small, one-room homes built of concrete blocks. Many were unfinished, doorless, windowless echoes of life in the poorest country in the hemisphere. Once, crossing over a river of open sewage, I asked, “Is this Cité Soleil?” “Not yet,” responded Dale. Ten minutes later, we took a left turn. The narrow road dropped 10 feet in elevation, flattened out, and plunged straight ahead into a seemingly endless plain of cardboard and tin shacks. Footpaths snaked between the shacks, and wisps of smoke rose from the open fires used for cooking. The smell of urine and feces intermingled with smoke and the aroma of cinnamon and vanilla. There was even more life in the streets—buying, selling, sidewalk industry—than in

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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. People wearing rags and naked children bathing in washbasins or chasing each other between the shanties mixed with people in starched white shirts, lace-trimmed dresses, or school uniforms. “This is Cité Soleil,” Dale informed us. The only other motorized vehicles on the road were trucks and Caterpillars hauling out piles of garbage. The government had made Cité Soleil its first priority for garbage removal. “How silly,” I thought, since the whole encampment was built on a pile of mud, rocks, puddles, and trash. Whenever the process of trash removal slowed our progress, children again surrounded us, gently asking for money. The adults occasionally smiled and waved but, in general, paid no attention to us, as if it would be impolite to stare at such strange people in such strange vehicles. Although human voices sounded everywhere, without the noise of the automobiles, there seemed a strange aura of peace in Cité Soleil. It was even quieter in St. Catherine’s Hospital, which rests behind a wall in an enclosure that includes a school and an orphanage. It’s located in the further reaches of Cité Soleil, a short distance from Port-au-Prince harbor. From the second story of the maternity ward, we could see children playing and women washing their clothes in a sewer lake the size of a football field. In fact, one can see all of Cité Soleil from that vantage point, a tribute to its flatness, the low height of its huts, and the compactness of the area, home to 200,000 people. St. Catherine’s was run by a private group under contract with the Catholic Church. Compared to the university hospital, it was functional. Here, there were nurses in the wards, clean sheets on the beds, and a food service. Most touching was the maternity ward. Most births in Haiti take place at home, but conditions in Cité Soleil were so unhealthy that St. Catherine’s promoted “intensive” prenatal care and in-hospital delivery. There was still crowding, with two mothers in each bed, 60 mothers all told, along with their newborns. In St. Catherine’s the newborn child was kept with its mother, who nursed it as needed. I was struck with the contrast to our nurseries in the United States, with their plastic bassinets, confining blankets,

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti and bottles of formula. Why should a newborn spend the first days of its life mostly in isolation? I thought. Three sets of twins were born the day we were there. One set was nursing simultaneously, one on each of their mother’s breasts. Perhaps there were things we would learn from Haiti, despite its problems, rather than assuming that coming from the United States we knew it all. “This is better. Don’t you think?” I said to Ruth, the nurse from Miami’s homeless clinic, as we were leaving. Touring St. Catherine’s, I didn’t notice that she had dropped out of the tour in the maternity ward or that she had been crying. “Better?” She whispered incredulously. “What hope for life could these children possibly have? You saw what we drove through to get here. They’ll stay in the hospital for two days and then go home to what? A dirt floor, a cardboard roof, and an open fire? It’s so sad. They have nothing.” I invited Ruth to join the team because I hoped her experience running the homeless clinic in Miami would translate into practical advice as to how to address primary care and nursing issues in Haiti. Based on our prior work at Camillus Health Concern, I knew I could count on her for no-nonsense answers. “They have their mothers’ love, and their fathers’, too.” My words convinced myself, but I’m not sure they convinced Ruth. “Get real, Art,” she came back at me. “This is one notch above hopeless.” That afternoon, on the way back to the hotel, our caravan ventured down one of the few paved side streets in Cité Soleil. The Pajeros stopped so that the journalists from the Herald and Channel 10 could take pictures of children playing in the open drainage. There was not a tree or a blade of grass in Cité Soleil, only people, animals, shacks, and trash. Our vans were surrounded by 30 to 40 children, laughing, smiling, begging, and reaching through the open window to touch us. I spoke my first words in Creole: “Nou pa genyen lajan” (“We don’t have any money”).

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti “W’ap ban mwen valiz-la?” (“Will you give me your purse?”) These words, almost sung in a sweet soft voice, came with a smile from a young girl with an angelic face. She pointed to Ruth’s pocketbook wedged between us. “She’d like your pocketbook, or its contents,” I translated. I was just starting to crack the code between French and Creole. “W’ap ban mwen valiz-la?” the girl repeated. She was almost nonchalant, with her head nesting on one arm, while the other reached forward to stroke Ruth’s leg. She was pressed against the van by the other children behind her but did not seem to care. “Ou trè bèl” (“You are very pretty”). “Mèsi, msye” (“Thank you, sir”). “Kijan ou rele?” (“What’s your name?”). “Regine, msye” (“Regine, sir”). I wished for a moment I could take her and all her friends home with me. Some had the red hair and swollen bellies from malnutrition, but most were apparently healthy and some stunningly beautiful. “W’ap ban mwen valiz-la?” When she realized we wouldn’t give her the purse, she became content to stroke Ruth’s dress and leg with her extended finger. She appeared about 12, her budding breasts partially exposed by her tattered T-shirt. Her companions on my side of the car asked for the four Dixie cups we had used for drinking water and that were kept in the back of the van. When I gave them the cups, the lucky four ran off to play with them in the drainage, followed by an envious entourage. Regine and several others stayed with us. I wondered how many other strangers she had begged from. How unreal to be sitting in the middle of Cité Soleil, surrounded by 200,000 of the poorest people I had ever seen. I had more money in my wallet than any of these children’s parents (if they had parents) earned in a year—maybe 10 years. And yet there was no sense of danger. In fact, there was a mystifying aura of peace, fostered by the absence of cars and the softness of the children’s voices. Then a dark thought entered my

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti mind. Anyone who wanted to could take advantage of these children. Any one of them, boy or girl, could probably be had for as little as a quarter. I thought back to our article about AIDS among Haitians and the controversy it had generated. While our critics were wrong in claiming that our patients were all gay, perhaps there was a grain of truth in the assertion that gay men had been coming to Haiti and giving money to young boys for sexual favors. It probably was not just a gay thing, though. There were probably plenty of straight men making the short flights from Miami or New York to buy sex from Haitian girls and women. Exploitation has no sexual orientation. There had been much debate in the medical journals and the press as to whether the virus evolved in the United States and was transmitted here or vice versa, or in some entirely different place (we now know it probably originated in Africa). But seeing Cité Soleil, I could only wonder what the point of the debate was. Wasn’t it just another way of fixing blame? There had already been too much blame, I suddenly realized, and not enough understanding. If anything, it was politics, economics, and exploitation that spread the virus. For that we’re all responsible and we’re all to blame. The majority just loves to pin the blame on a minority, particularly one that can’t fight back. As I sat in the van, surrounded by squalor, another thought struck me. The temperature was 90 degrees. The sun was heating up the water seeping through the garbage, and every possible combination of genetic material—human, viral, and bacterial—was fermenting in the water percolating through Cité Soleil. Children and adults were washing in, drinking, and excreting this water, walking or playing in this soup, sometimes with cuts or open sores on their feet. My God, we’ve created the world’s largest Petri dish, I thought. In this soup of human and non-human DNA, anything could evolve. I never for a moment actually believed my fanciful Petri dish theory but was intrigued with it nonetheless. How much easier it would be to fight AIDS if only its origins were unrelated to sex. AIDS could

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti have started here, in Lagos, or perhaps in Bangkok. It didn’t matter where it started. Poverty was the issue, not sex, and we could do something about that. The Petri dish theory did have an ominous corollary. The more the virus replicated, the more opportunities it had to evolve new strategies to kill people. If, at the present time, one couldn’t get AIDS from splashing in or drinking contaminated water, there was no guarantee that it wouldn’t happen in the future. In their quest for survival, germs have proven remarkably ingenious. For example, the germ that caused the Black Death evolved two ways to infect humans: one through the bites of rat fleas and the other from person to person through the air we breathe. The rats and their fleas, coupled with the masses of people that crowded European ports in the 14th century and the crowded living conditions they endured, set up a double-barreled killing machine that wiped out half of Europe. But the real Petri dishes were the tens of thousands of people living here and in places like here—walking culture media—who don’t know they’re infected and couldn’t do anything about it anyway. So, whatever its origin, a virus has evolved that’s smarter than we are, smarter because it attacks our three greatest weaknesses—our immunological defenses, our sex drive, and our social order. And as Tim had predicted, it always stays two steps ahead of us. Back in the States we’re still debating about confidentiality, voluntary testing, and condoms. How can you expect safe sex to be practiced in Cité Soleil or, for that matter, any place that’s desperately poor, or by the mentally ill, or by crack addicts on the streets of Miami? The real risk factor is not being gay or Haitian or a drug user. It’s being a social outcast. AIDS is like a zombie curse, a judgment cast on a victim. People with AIDS are victims of a disease, and we blame them for it. Then they exist, half-alive, half-dead, enslaved by their diagnosis. And we, as a society, are not going to do anything about it because we must want it this way. Otherwise, we would change things. And why do we want it this way? At best it’s because we’re all wrapped up in our own lives, and who has time to care about places out of sight,

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti like Cité Soleil? At worst, our inertia must spring from an attitude that “someone’s got to win and someone’s got to lose.” The Haitians seemed to be losing at every turn. To my way of thinking, even if you didn’t give a fig about these poor Haitians and were only motivated by enlightened self-interest, the Petri dish corollary said it would be a big mistake to tolerate conditions like those in Cité Soleil and not try to change them. All these thoughts raced through my mind in the short time it took for Regine to run her finger across Ruth’s leg. I thought of my own daughters. What accident of birth or stroke of fate destined them to a life of comfort in Miami and Regine to be begging and perhaps prostituting herself to strangers in Cité Soleil? “Wake up,” I told myself. “You can do something about this!” “I wonder what happened to our journalists,” murmured Ruth, looking over her shoulder out the back of the Pajeros. The crush of children and Regine’s stroking her leg were unsettling to Ruth. Each passing second made it more and more difficult to resist Regine’s persistent pleas. The journalists finally reappeared. “Unbelievable shots!” they exclaimed as they piled into the van. That one trail carved out by that trickle of water led us further and further in, and it got darker and narrower, with no end to the people. Seven or eight in each shack—that sort of stuff.” “I’ll bet AIDS is a problem here,” I said to no one in particular. “They say in some parts of Cité Soleil that everyone has AIDS,” one of the journalists responded. It was almost impossible to make a U-turn in the narrow street we were in. In the process our driver knocked over a tripod pot containing a soup or stew. That brought out from the owner the only words of anger I heard during my first trip to Haiti. After changing direction, we slowly drove away, with the children running after us, half singing, half shouting, “bonswa, bonswa!” That night, back at the hotel, I allowed myself the luxury of a bottle of wine after dinner. I sat on the terrace sharing the day’s

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti events with the Haitian-Americans in our group—Michel, Henri, Ron, and Junia. I discovered we all shared the blessings of a Catholic education: a broad base of philosophy, theology, and history, with the church’s particular spin. My education and Junia’s, guided by the Augustinian fathers in the United States, had emphasized philosophy and theology. Michel, Henri, and Ron, taught by the Jesuit fathers in Haiti, were strong in history, language, and politics. Michel could translate both Latin and classical Greek. He laughed at how hard he had studied those subjects for so many years. “What relevance do Latin and Greek have to life in Haiti?” He asked. “But the good fathers believed we needed a classical education.” Junia mentioned how hard it was going to school in Miami. Her parents had immigrated so that their children could get an education. Her schoolmates teased her relentlessly about her language and her clothes. All lamented how many traditional values were lost in the process of Americanization. I confessed my role in the Haitian AIDS study. They all looked at me with an expression that said, “Art, how could you have done such a thing?” Unfortunately, the study was infamous for the political fallout it had caused Haitians. I realized that all my colleagues had experienced the unspoken accusation—“You’re Haitian. You must have AIDS.”—and I was partly responsible for that. After only two days in Haiti I had come to realize the absurdity of lumping all Haitians together. Here was Michel, light-skinned progeny of professional-class parents, sitting beside Junia, coal dark, whose father died when she was young and whose mother worked as a custodian. And then there was Régis, my “blood brother” dentist, and Regine, the young girl in Cité Soleil. What did they have in common? Yes, they were all Haitian, but that was about it. So why would being Haitian put you at risk for an infectious disease? How naive we had been. I explained how my thinking had changed, about my thoughts in Cité Soleil, the Petri dish theory, the zombie curse theory, and, most importantly, what Ruth and I had learned from Regine. All

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti remained silent for a while, pondering the gravity of my assessment. We then launched into a serious discussion of all the factors that might drive poor people anywhere, not just in Haiti, to sex early and often, the status of women and their dominance by men, prostitution as a survival strategy, family breakup for economic or political reasons, emigration, lack of education, lack of health care, and lack of hope for the future. Then one of the journalists interrupted to tell us that a famous Haitian singer was there in the hotel and was going to sing for us. Beethovan Obas and his brother Mozart gathered us together in another part of the terrace. His stage name when spoken, not as spelled, in Creole means “Down with Beethoven.” His music was a blend of jazz and island beat, sometimes in French, usually Creole. The sound was soft, upbeat, and happy. But if you understood the words “Ayiti Mouri” you would see that they mean “Haiti is dying.” As he sang, the Haitian faculty joined in the chorus: “Nou pa, nou pa, nou pa, nou pa …” (We’re not, we’re not, we’re not, we’re not.”) He was left-handed and played his small acoustic guitar upside down, inventing new cords and finger formations. We sang until after midnight, until an American businessman came out of his room and screamed that we were keeping him awake. Junia, Henri, Ron, Marlon, and Jerry decided they would take Barth, Ruth, and the others out to a Haitian disco. “How can you go dancing after what we saw today?” I asked them. “Haiti is like an onion, Art,” philosophized Henri, solemnly. “You’ve got to peel away one layer at a time. What we saw today is why we dance.”