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Tom’s World

Six weeks later …TI POUL, DELVA! TI POUL!” cried Susan S. from the passenger side of our rented truck. She clutched the dashboard as if it were a brake lever. “Pa gen pwoblèm,” chuckled Delva as he swerved the truck to avoid the latest mother hen and chicks to dare cross our path as we bounded and crunched our way from Pignon to Thomonde. The swerve lifted us out of the rut that traffic had worn in the dirt road. Although Delva was accommodating to Susan’s desire not to kill any chickens, he was not going to slow down. We had to get to Thomonde. There would be lots of patients waiting.

Ti poul-yo,” I corrected Susan’s Creole. “There is more than one chicken.” It had become a running joke now: Susan’s “I brake for animals” vigilance balanced by Delva’s determination to complete the four-hour road trip from Thomonde to Pignon to Thomonde by 10:00 a.m. Every time we bounced on a boulder the students in the truck bay would scream “Yahoo!” Children watched us cautiously from behind their cactus hedge rows or ran laughing after us yelling, “Gade blan! Gade blan!” (“Look at the strangers!”)

Seeing “blan-yo” in this part of Haiti, deep in the interior, close to the Dominican border, eight miles from anywhere, was certainly an event. I had kept my promise to Delva to come back with a team



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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Tom’s World Six weeks later … “TI POUL, DELVA! TI POUL!” cried Susan S. from the passenger side of our rented truck. She clutched the dashboard as if it were a brake lever. “Pa gen pwoblèm,” chuckled Delva as he swerved the truck to avoid the latest mother hen and chicks to dare cross our path as we bounded and crunched our way from Pignon to Thomonde. The swerve lifted us out of the rut that traffic had worn in the dirt road. Although Delva was accommodating to Susan’s desire not to kill any chickens, he was not going to slow down. We had to get to Thomonde. There would be lots of patients waiting. “Ti poul-yo,” I corrected Susan’s Creole. “There is more than one chicken.” It had become a running joke now: Susan’s “I brake for animals” vigilance balanced by Delva’s determination to complete the four-hour road trip from Thomonde to Pignon to Thomonde by 10:00 a.m. Every time we bounced on a boulder the students in the truck bay would scream “Yahoo!” Children watched us cautiously from behind their cactus hedge rows or ran laughing after us yelling, “Gade blan! Gade blan!” (“Look at the strangers!”) Seeing “blan-yo” in this part of Haiti, deep in the interior, close to the Dominican border, eight miles from anywhere, was certainly an event. I had kept my promise to Delva to come back with a team

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti of medical students to do a health fair in Thomonde. By screening for common, preventable, treatable problems, such as worms and malnutrition, we could start the process of returning health to Thomonde. Project Medishare was not an official part of the University of Miami’s curriculum, but word was passing from student to student that there was a real opportunity to learn in Haiti. As a consequence, more and more students were giving up their spring, summer, and winter breaks and volunteering for Medishare. On this trip I had 12 second-year medical students, long on book knowledge but short on experience. I was the only real doctor. But that was the wonderful thing about the health fair method: One doctor aided by a dozen students could see a lot of patients. Delva showed me the Uzi he kept under his seat. As magistrate of Thomonde he carried absolute authority, and he wanted us to know that he personally guaranteed our safety while visiting Thomonde. The students were impressed with the Uzi, particularly since the Miami Herald had written another series of articles about gang violence and police ineffectiveness in Port-au-Prince just before our trip. Delva was more concerned about reports that there were barricades blocking the road around Hinche. The report turned out to be nothing more than rumor. Neither barricades nor gangs ever materialized. I wasn’t worried. In my 20 trips to Haiti in Medishare’s first two years of existence, I had learned that there were really two Haitis—the political Haiti you read about in the newspaper and the real Haiti hardly anyone outside the country ever sees. In the media’s version of Haiti, the country was in a perpetual state of political violence and crime. In the real Haiti, at the time, political violence was frequently more symbolic than real, a kind of political theater, usually confined to the capital. Crime in the countryside in those days was practically nonexistent. In Haitian culture the worst thing you could possibly be is a thief, a vole. People policed themselves. And if anyone should seriously break the rules, there was always the threat of the zombie curse. Certainly, I had seen some petty theft in Port-au-Prince. There

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti was one street corner near the airport where youth gangs looked for tourists in unlocked cars, opened the doors on the run, and tried to steal purses or jewelry. My Haitian friends said these were second-generation Haitian-American youths who grew up in New York City, were corrupted by America, and were then deported after criminal convictions. “They don’t even know Creole,” I was told. Even with this pocket of petty crime, Port-au-Prince seemed much safer than Miami. And in contrast to the capital, there was simply no crime in Thomonde. Neither Delva nor the people would tolerate it, and in Thomonde there would be no place for vole to hide. Besides, as Dr. Paul had put it, the poverty was “decent” in Thomonde. Every peasant proudly worked his own little plot of land, compared to the “indecent” poverty of the uprooted masses in Port-au-Prince. During my first visit to Haiti, I was amazed at the peace and security I sensed in Cité Soleil. Now the politics were so unstable that my Haitian friends advised me not to take any students in there. Fortunately, Medishare now had Thomonde. There were only a few AIDS cases identified in the commune of Thomonde at that time, probably because it was so isolated in the interior and because there were no doctors to diagnose it. The low numbers would surely grow. There were many cases down the road in Cange and even more in Mirebalais. There was more extreme poverty there, increasing the number of people traveling to and from the capital looking for work, forcing more women to turn to prostitution and more men to leave their families to cut cane in other parts of Haiti or in other countries, particularly the Dominican Republic. As tortuous as the drive from Port-au-Prince had been, the road is the only link between the countryside and the capital. In Haiti the AIDS epidemic had evolved in a classic pattern, first appearing in the slums of Haiti’s ports and tourist centers and then slowly spreading to the countryside. Paul had already demonstrated how the road facilitated this spread of disease. The two vectors? The police (if you were a Haitian peasant, you couldn’t say no to the police in the 1980s) and the tap-tap drivers.

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti A Thomonde granmoun. Photo by Wassim Serhan. I was skeptical about the estimates I had been given by Delva and Paul about the number of tuberculosis cases in Thomonde. As we were driving around the commune, however, I could visibly identify people with telltale signs of consumption. From the perspective of the victims and their neighbors, it probably made no difference whether they were suffering from AIDS or from the more ubiquitous tuberculosis. I quickly learned that Western medical diagnoses mattered little there. All that mattered was that the people were visibly marked for death. We pulled off the road and into the field that surrounded the newly finished magistrate’s office. Hundreds of people who had gathered outside cheered our arrival at exactly 10:00 a.m. The day before we had seen about 200 children—plotted their heights and weights, identified those who were malnourished, and treated the ones with worms and impetigo. We had promised the granmoun (the adults) that we would see them today, but first we had to transport the

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti sickest children to the hospital in Pignon, about two hours away. Some of the students stayed behind to give health education classes on malnutrition, oral rehydration, family planning, and HIV prevention. “N’ap kòmanse nan senk minit. Mèsi pou pasyans ou!” (“We start in five minutes. Thanks for your patience!”), I announced as I pushed through the crowd and past the iron gate entrance to our makeshift clinic. “How’d the classes go?” I asked the students gathered in the central foyer. “Great! You could tell by the questions the patients asked that they were really getting it. Jean-Gason and Jean-Peter [two boys from the local school who were fluent in English and had volunteered to translate] did a super job!” volunteered Susan A. “But Dr. F. We’ve got a problem.” “What’s that?” “All those people want to be seen! We counted nearly 600.” “Well, I guess we’d better see them. We’ve got 12 students, so that means two students in each exam room, plus two to guard the gate and regulate patient flow, and two to man the dispensary. Organize yourselves, and let’s get started.” The crowd was already pressing against the iron gate, but the people backed away just enough for me to exit and announce, “Granmoun premye!” (“Old folks first!”). In Haitian culture old people are revered. Granmoun, which means “old person,” also means “wise person.” Adhering to this tradition, we decided to see the oldest patients first. The sea of people in front of the gate parted as four men carried in the oldest citizen of Thomonde on a palette and helped her into an easy chair. “Bonjou, dokte,” she said as she was carried by me. “Bonjou, mami,” I responded. “Susan, Felix—would you please take this first patient? Use Jean Peter to help you.” Remarkably, in 10 minutes the clinic was in high gear. The students performed limited histories and physical examinations, while I rotated from room to room, identifying the problems and how we’d

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti treat them. Then the patients would go to the “dispensary” (a table set up in the central foyer with the essential medicines we had brought from Miami) to pick up their medicine. The only problem was that there was only one gate out, and everyone was trying to get in. “Dr. F., This first patient says she’s 115 years old. Could that be right? “It’s probably pretty close, since her daughter who’s with her tells me she’s 84.” “What do you want us to do for her?” “Find out why she can’t walk. Do a complete exam. Don’t worry, take your time.” After an hour it was clear that the patient’s complaints could be grouped into certain general types of problems—bouton, gratél, and other skin conditions; heart problems; fevers; masses and hernias. Though the makeshift clinic was running pretty smoothly, we had a major problem: How to get the patients we had already seen out without letting the increasingly anxious crowd in. “We’ve finished our exam and don’t find anything terribly wrong,” said Susan A. “She’s just a little unsteady on her feet,” referring to the 115-year-old woman. I stopped my running from room to room when it hit me. “That’s the oldest person I’ve ever met … and probably ever will!” I went over to talk to her—a sweet woman who looked remarkably like her daughter. She would like to walk but was afraid of falling, she said. “We’ve got this walker we carried from Miami. Do you think that would help?” volunteered Felix. “Great idea!” Five minutes later the 115-year-old woman who was carried in walked out under her own power. The crowd roared its approval. This seeming miracle, though, only increased each person’s desire to be seen, so the crowd pushed even harder to get through the gate. The windows of the magistrate’s office were open, with the hands

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti and faces of children pushing through. One of the hands gave me a note. It was from a child with asthma we saw the day before. I wanted to see him back for a recheck and had instructed him to meet me at the front gate. I went out through the crowd and found him and led him in by the hand. The crowd, if anything, was getting bigger. “Dr. F, we’ve reached gridlock. No one can leave. They’ve pressed so tightly against the gate, so we can’t bring in anyone new,” exclaimed David, one of the gate’s guards. “I’m a little worried someone might get hurt.” “I think we’ve got a revolution of rising expectations on our hands,” I muttered and then attempted crowd control to no avail: “Pa pouse, pa pouse!” (“Don’t push!”) David and Tom were leaning all of their weight against the gate to keep it shut. Finally, the hinges gave way and the 500 citizens of Thomonde still waiting to be seen poured through the gate and down the two corridors of the magistrate’s office. “All of you, stop seeing patients! Gather up your things! We need to get out of here!” I screamed as I withdrew to the central foyer. In five minutes, as the last of the patients streamed in, the students and I were able to march out, single file, carrying our precious medicines in duffel bags. I announced in Creole that people needed to leave the magistrate’s office immediately or we would never return to Thomonde again. It seemed like I was the only one who took the situation seriously. The patients were laughing and the students were smiling, amazed by the spectacle of it all, as we retreated toward the truck. A circus atmosphere prevailed. Delva, who had been working on making us lunch, came running over from his house, looking worried. “Kisa k’ap rive?” (“What’s going on?”), he asked me as he caught his breath. “Yon ti revolisyon, se tou” (“Just a little revolution, that’s all”), I responded. Delva’s voice obviously carried more authority than mine. “Sòti kounye-a!” (“Get out now!”), he barked, and in minutes his office was empty again. He told the patients we were going to take a

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti lunch break and reorganize, that we’d return and would attempt to see everyone, once we had established a reasonable plan. Delva whisked us away in the truck to a secret place—a relative’s house—where we huddled to see how we could solve the patient flow problem. We returned to Delva’s office by 3:00. We had the patients form four lines—one for skin problems, one for heart/blood pressure, one for fevers, and one for masses and hernias. These groupings were important. Although it’s true that few people died of skin problems, the misery they caused was extreme and they were easy to treat, which would build confidence among our patients in Western medicine. The fever line was critical. With a few simple questions we could sort out patients with malaria, which we could treat on the spot, from those with suspected tuberculosis, whom we’d have to send en masse to Dr. Paul in Cange. The hernia line might seem trivial, but with the only surgeon in the region two hours away in Pignon, I knew that we’d find a lot that had never been repaired. In Thomonde a hernia could keep you from working, and if you couldn’t work, you couldn’t feed your family. Each student team was assigned to a single line, with each line forming outside a single room. We were back in business again, each line moving at a noticeable pace, and with no pushing, or pressing. “What are we going to do with all these hernias?” asked Ian, one of the two students in the hernia room. “We’ll take the four worst ones with us to the hospital in Pignon tomorrow. To the rest, we’ll explain, that if it gets stuck and won’t go back inside, it’s an emergency and they’ll need to go to Pignon. Otherwise, we’ll try to bring a surgeon back and fix some more when we return in July.” Miraculously, by 10:00 p.m. we had seen all the patients in each line, and the students were finishing up on the last patients in each of the exam rooms. We were almost out of medicines. While I was physically exhausted, my mind was in overdrive from the stimulation of seeing 600 patients. I was proud that we had kept our prom-

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti ise to see every patient, and I told the students so, but now it was time to quit. The generator that Delva had rigged to give us light would run out of diesel fuel soon. I told a few curiosity seekers on the front steps that we had to stop. We needed to be up at 5:00 a.m. to take the patients with hernias to Pignon. “Dr. Fournier, you need to see this kid,” said Tom as he approached me from behind. “We saw kids yesterday, Tom, and it’s time to quit….” My sentence trailed off as I turned to face Tom, holding a limp infant in his arms. “His mom carried him from way out in the countryside. He’s had diarrhea for two or three days and he’s not nursing well,” explained Tom, sounding almost apologetic after my rebuke. A quick exam on the front steps while Tom held the infant in his arms revealed a limp, sluggish, and difficult to arouse four- or five-month-old baby. The sunken soft spot in his skull, dry mouth, and wrinkled skin made the diagnosis of life-threatening dehydration obvious. “Sorry, Tom. You’re right. Take this child and his mom inside. Mix up some oral rehydration therapy. Do you remember the formula? Two liters of water, a half cup of sugar, and a pinch of salt.” Tom (holding the baby), and the mother ran up the steps to one of the exam rooms. I tried to treat my own dehydration with one of the Haitian colas provided by Delva. “What’s next?” I asked myself as the cool soda soothed the back of my throat. After coaching 12 medical students through the care of 800 patients over two days, I needed a break. As if on cue, Tom appeared. “Uh, Dr. F. We’ve mixed this stuff up, but how do we give it?” Of course, there were no baby bottles in Thomonde! I walked over to the exam room where the child was sprawled limply on the bench. By now the students had gathered round, all looking to me for a solution. Momentarily stumped and straining for an answer, I explained the signs of dehydration that the child exhibited and how

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti dehydration from simple diarrhea was the major cause of death in children in Haiti. In my mind, however, I was searching for an answer to the immediate problem. A straw, with force feeding? We had no straws. The finger of a latex examining glove stretched over a cola bottle and pricked with a needle to form an artificial nipple? No, the latex was too thin for even an infant to suck on. We had already distributed all of our condoms. Then, suddenly. “Get a syringe, Tom, and take the needle off the hub.” Tom ran to the dispensary and brought back one of our few remaining syringes. I filled the syringe with oral dehydration solution and offered the hub end to the baby’s mouth while I applied gentle pressure to the plunger. The infant’s lips and tongue instinctively wrapped around the hub, and a few seconds later the child swallowed. It was going to work! “O.K., students, we’re going to rehydrate this infant one cc at a time. Each of you take turns doing exactly as I’m doing; then we need to teach his mom how to do it herself. She’ll have to get him through the night. If he makes it, we’ll take him up to Pignon with us tomorrow. I’ll ask Delva if he can find a home they can stay in tonight.” The child’s mother was a quick learner, and in what seemed like no time the child had consumed 30 cc’s of the solution. Already, he seemed more active and more responsive. I sent her off into the darkness with Delva and a two liter bottle of the rehydration solution, with instructions to give the baby as much as he wanted and to be back at 5:00 a.m. for a ride up to Pignon. I told the students to clean up a bit—we had really trashed Delva’s office—and then gave the order to douse the generator. We plunged into darkness and climbed into our cots or sleeping bags. Despite my exhaustion, I had difficulty falling asleep. Voodoo drums pounded in the distance. In the gray zone between sleep and consciousness, the first few minutes of hearing voices in Creole and English made me think I was hallucinating. I forced myself to focus on where the voices were coming from—outside on the steps. I

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti A mother in Thomonde with a large number of malnourished children. looked at my watch on the chair next to me but could not see it in the dark. I got up and lit a candle: 2:00 a.m. I pulled on my shorts and stumbled toward the gate. Jerome (the troubadour of Thomonde, Jean called him) and two of his friends were talking earnestly with two of my students about music and philosophy. Jerome had stopped by earlier to entertain us, but we were still seeing patients. Evidently, the students were having trouble falling asleep also. I met Jerome on my first visit to Thomonde. Delva arranged for him to play for me and my students. Not only does Jerome sing in French, English, Spanish, and Creole, but he also writes his own songs. He’s lived his entire life in Thomonde, except for an occasional visit to Port-au-Prince. In my mind, he’s the perfect allegory for Haiti—so unique, so talented, so unjustly unknown. Jerome played his guitar and his three Haitian friends harmonized on a simple folk song about a young Haitian who goes to the Dominican Republic to cut sugar cane to earn money for his family and whose wife leaves him for another man while he’s gone. We finally broke up at 3:00 a.m. When I awoke 90 minutes later, I was surprised at the early morning activity in Thomonde. People were already cleaning

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti their stoops, washing clothes, or filling water buckets at the village spigot across the path from Delva’s office. I wanted to be ready to go when the students, who were due to be up at 5:00, arose, so there I stood at the spigot, washing myself and sharing my soap with the early-rising Thomondois. The flatbed truck that Delva had arranged to take us to Pignon arrived precisely at 5:00, along with the four people with hernias and the mother, the infant, and an almost-empty bottle of rehydration solution. The child was so much better—alert, aware, squirming in his mother’s arms, that I almost considered not taking them to Pignon. On the other hand, a couple of days of observation to make sure the child didn’t relapse wouldn’t hurt. His mother had dressed him up in a small suit and booties. The students trickled out of their rooms, threw their gear in the truck, and climbed aboard. Mother and child were sitting on the spare tire, along with Tom, who wanted to be close to his “save.” The other students stood, holding on to the side bars and crossbars of the truck as we jerked into gear and headed up the road. I waved to my bathing mates at the spigot as we left. “Abyento!” Jerome’s song from the night before kept running through my head. It stayed with me all the way to Pignon.