Cover Image

Not for Sale



View/Hide Left Panel

Au Cap

BY 2003, ENTERING ITS NINTH YEAR, Project Medishare had evolved from a small group of volunteers to a full-fledged charity. We had been successful enough in our fundraising to be able to hire a full-time executive director to develop year-round programs. Our mission was also evolving. Barth’s original concept had been a somewhat limited project: Concerned faculty at the University of Miami would provide technical assistance and training to Haitian doctors and nurses while South Florida health institutions donated surplus usable equipment and supplies. As we became more engaged in Haiti, we morphed into something more unique and significant—in effect, a multidimensional human resource project, developing the potential of our own students and faculty to be compassionate and effective doctors while developing Haitian human resources that would contribute their own solutions to Haiti’s health problems. In this regard (I wish I could say we planned it this way, but actually it just kind of happened) we had created two distinct human resource programs. In Thomonde we were working directly with the people to improve the health of the community through peer educators and facilitators—people Paul referred to as accompagnateurs (companions), similar to the barefoot doctors of China. At the same time, in



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 249
The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Au Cap BY 2003, ENTERING ITS NINTH YEAR, Project Medishare had evolved from a small group of volunteers to a full-fledged charity. We had been successful enough in our fundraising to be able to hire a full-time executive director to develop year-round programs. Our mission was also evolving. Barth’s original concept had been a somewhat limited project: Concerned faculty at the University of Miami would provide technical assistance and training to Haitian doctors and nurses while South Florida health institutions donated surplus usable equipment and supplies. As we became more engaged in Haiti, we morphed into something more unique and significant—in effect, a multidimensional human resource project, developing the potential of our own students and faculty to be compassionate and effective doctors while developing Haitian human resources that would contribute their own solutions to Haiti’s health problems. In this regard (I wish I could say we planned it this way, but actually it just kind of happened) we had created two distinct human resource programs. In Thomonde we were working directly with the people to improve the health of the community through peer educators and facilitators—people Paul referred to as accompagnateurs (companions), similar to the barefoot doctors of China. At the same time, in

OCR for page 249
The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Hôpital Justinien, Cap Haitien, home of the Family Medicine Residency Program. Cap Haitien and Pignon, we were training Haitian doctors in what was, for Haiti, a revolutionary approach to health care. A historic and revolutionary program deserves a historically revolutionary setting. Cap Haitien, the principal site of our family medicine residency program (we also used Dr. Guy’s hospital in Pignon for training), was the colonial capital of Saint Dominique. In 1791, slaves in the surrounding countryside, taking advantage of the chaos created by the French revolution, rose up against their masters. Legend has it that a Voodoo dance was the sign the slaves chose to signal the start of the uprising. The revolution lasted 13 years before Napoleon withdrew his troops and recognized Haiti’s independence. The costly, failed expedition to recapture France’s wealthiest colony forced him to sell his Louisiana territories to the United States. Haiti be-

OCR for page 249
The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti came the first black republic and the second (after the United States) republic of modern times. The historic old city, once referred to as “the pearl of the Antilles,” is now in a sad state of disrepair. Balconies have collapsed, and tile roofs have caved in. Practically every home needs a fresh coat of paint. Peasants fleeing the desperation of the countryside have squatted in the hills and along the river that leads to its port, transforming it into a mini Port-au-Prince, with slums of cardboard and tin shacks swarming with thousands of people. Chaos reigns in the charcoal and iron markets. Its beautiful natural harbor is visibly polluted and its carrefour littered with trash. Its charm is still apparent, however, to the discerning observer. The hotel I stay at—the Roi Henri Christophe—was built in 1724 and was part of the original governor’s palace. When I walk from the hotel to Hôpital Justinien, past the crumbling colonial houses, past the Place D’Armes, where Mackandal, the first slave to attempt a revolt, in 1715, was burned at the stake and where Ogé, in 1792, was broken on the wheel, I’m reminded of the history of Haiti’s tragic birth. The cathedral was built in 1630, the year my home-town, Boston, was founded. In 1630, Miami was an Indian village and would remain so for almost 300 more years. In the mountains on the other side of the Grande Plaine du Nord, Christophe’s fortress, the Citadelle, juts above the geologic skyline. Not far is Breda, the plantation where Toussaint L’Ouverture, Haiti’s first leader, was born and Vertierres, the site of the last rearguard action of the French before they abandoned their former colony. Their place in Haiti’s history is not lost on the Capois, who fight their own rearguard action against the continuing neglect and decay of their city. André was right to choose Cap Haitien for our family medicine training program. Hôpital Justinien is arguably the best-functioning government hospital in the country. Port-au-Prince is a snake pit of politics and intrigue, even in the health sector. Au Cap, André was on good terms with the hospital director and the

OCR for page 249
The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti regional health minister. They agreed to pay for the program’s staff and the residents’ stipends. André had trained as a surgeon at the university hospital in Port-au-Prince. During his year of social service in the town of Fort Liberté, he realized how poorly his training, although technically quite competent, had prepared him for the vast majority of problems that beset his patients. He used to go up on the old fortress wall that jutted into the harbor and contemplate what he could do for his beloved Haiti. The answer he came up with was to immigrate to the United States, become a family practitioner, and then return to Haiti and establish the discipline there. André was therefore our “ace in the hole” in terms of delivering the goods for the grant from the Open Society Institute. In his mid-40s, with a gray-flecked beard, piercing hazel eyes, and a stern countenance, André sprang from the Haitian intelligentsia. His grandfather had been a minister of justice. He himself was an intellectual—“always reading and writing” his mother would say—and a lifelong student of Haiti’s history. Intense, focused, single-minded, with the goal of creating Haitian generalist doctors with broad-based skills, he had committed to spending six months each year in Haiti, making sure the program took hold. Establishing a new discipline such as family medicine in a resource-poor country like Haiti is an arduous task. In fact, it had never been done before, at least not in a country as poor as Haiti. First André had to negotiate an agreement—a “convention”—with the ministry of health to make sure the project would continue even if the government changed. Then he had to recruit faculty members from the disciplines of general medicine, pediatrics, and obstetrics and bring them to Miami to learn to be family doctors, there being no precedent in the country. With Michel’s help, he drafted the curriculum and schedule. Finally, he needed to recruit five candidates into the residency program each year. It took a good three years for Haiti’s ministry of health to understand the significance of our training program. By that time our original grant from the Open Society Institute had run out and

OCR for page 249
The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Medishare had to pick up the costs. The family practice center—the heart of the program—had been forced to operate in renovated space in a building owned by another ministry. Plans to build a new center were put on hold, as it was all Medishare could do just to maintain the faculty. To understand how revolutionary our program really was, one first has to first understand the conditions at the hospital prior to our program. Hôpital Justinien was large, with open-air wards for pediatrics, obstetrics, general medicine, and surgery, each ward having enough beds for 40 to 60 patients. Nestled between the four main buildings were two completely inadequate buildings that housed the emergency room and the outpatient clinic. The entire complex was painted white with green trim—the colors of hope. Situated on a slight rise on the western edge of the historic district, it was designed to catch the trade winds that blew off the harbor—a kind of natural air conditioning. Most patients were admitted through the emergency room. Patients admitted “after hours” would have to wait for the doctors to come in the following morning before orders would be written to commence care. The medical staff—private doctors in practice in Cap Haitien—were paid a small amount by the hospital to visit each day, usually two hours or less, to provide care for the poor. The hospital had no functioning laboratory or x-ray unit. Electricity was available only two to four hours a day. Our program brought residents to cover the major services 24 hours a day. Furthermore, it provided faculty and residents with an outpatient setting to take care of small problems before they became disastrous and to address screening, prevention, and family planning. These changes, particularly the innovation of full-time faculty seeing patients and supervising residents, were at the heart of our revolution. Other changes were more subtle but no less significant. For example, we built, staffed, and stocked a pharmacy within our family practice center, where our patients could get their medicines at nominal costs. We also created a medical record that documented

OCR for page 249
The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti preventive and psychosocial issues and a curriculum that prepared trainees for most of Haiti’s health needs, including mental health. On the wall in the preceptor’s room, André hung his motto: “Respect, Compassion, Excellence.” It was a revolutionary motto. Prior to our program, social class dominated the profession of medicine in Haiti, as it did in so many other spheres of Haitian life. Medical education was free, but to enter medical school you had to pass an exam. This meant that, in effect, only the sons and daughters of the elite, who could afford a private education, could compete for entry into the profession. After completing traditional residencies in which students gained experience by treating poor patients with no real supervision, they would either enter private practice or emigrate to the United States or France. Never before in Haitian medical education had faculty and residents come together to serve the people. Poor places like Haiti simply can’t afford the luxury of one doctor for children, one for pregnant women, and one for adults, so family doctors were a critical need. It seemed so logical in theory, as Michel and I crafted the grant that got the program started. Three years into the program, the reality was even more compelling—residents and faculty working at the family practice center shoulder to shoulder, changing a 200-year tradition of learning at the expense of the poor into one of learning in order to serve them. The problem was sustainable financing. We had made believers of the folks at the Open Society Institute, our original funders, and they were willing to help us establish other training programs if the first program achieved financial independence. But the Haitian ministry of health had no money and other possible funders had “strings.” For instance, the only funds available from U.S. Agency for International Development were tied to a program to prevent HIV transmission from mothers to their children. United Nations Children’s Education Fund had specific priorities based on a national plan designed with the ministry that focused on nutrition, vitamin supplements, and immunization. Unfortunately, the argument that all of these disease-specific goals could be more easily addressed

OCR for page 249
The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti through the training of Haitian generalist physicians fell on deaf ears. Therefore, the onus for funding fell on Medishare. Medishare had accomplished great things in Haiti, but as a small “niche” charity, major fundraising had always been its Achilles’ heel. It was also stretched thin by its commitments to Thomonde and volunteer trips. Medishare’s board was growing restive with an open-ended commitment to the residency program and no end in sight. Other long-term sources of funding would have to be found.