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The Reverse Zombie Curse

December 2003. IN THE BATTLE FOR HAITIS HEALTH, Medishare was forced to open a second front. For years, we had been content to maintain a very low profile toward the medical school’s administration, quietly building our programs and developing support among our students and other faculty. But Medishare, by itself, had come about is far as it could. To go further, we’d need the complete support of the medical school. Unfortunately, Haiti’s bad press, coupled with the looming malpractice crisis in the United States, had convinced some—most notably the provost of the university and the general counsel—that the faculty and students of the University of Miami had no business volunteering in Haiti.

Malpractice insurance costs, rising everywhere in the United States, hit Miami particularly hard. The administration’s concerns were that some poor Haitian peasant would identify the University as a “deep pocket” or that a student would get sick or injured and that the University would be held responsible. These days even a school of medicine had to operate first and foremost as a business.

So a sort of chess game unfolded in which both sides made up the rules as we went along. In this makeshift game the object was to capture the support of the dean of the school of medicine. The



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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti The Reverse Zombie Curse December 2003. IN THE BATTLE FOR HAITI’S HEALTH, Medishare was forced to open a second front. For years, we had been content to maintain a very low profile toward the medical school’s administration, quietly building our programs and developing support among our students and other faculty. But Medishare, by itself, had come about is far as it could. To go further, we’d need the complete support of the medical school. Unfortunately, Haiti’s bad press, coupled with the looming malpractice crisis in the United States, had convinced some—most notably the provost of the university and the general counsel—that the faculty and students of the University of Miami had no business volunteering in Haiti. Malpractice insurance costs, rising everywhere in the United States, hit Miami particularly hard. The administration’s concerns were that some poor Haitian peasant would identify the University as a “deep pocket” or that a student would get sick or injured and that the University would be held responsible. These days even a school of medicine had to operate first and foremost as a business. So a sort of chess game unfolded in which both sides made up the rules as we went along. In this makeshift game the object was to capture the support of the dean of the school of medicine. The

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti administration’s opening move was to insist that we offer the students traveler’s insurance and that the students sign a waiver of responsibility before going to Haiti. For our part we strove to gain academic credibility for Medishare. Our students returned from each trip with glowing reports of how much they had learned. Furthermore, we also published an article in Academic Medicine, detailing Medishare’s educational merits. Our students published and presented at international health conferences their experiences screening for tuberculosis among orphans and their case series of children with congenital rubella. Our grant from the Open Society Institute to establish family medicine residency training in Haiti furthered our academic credibility enormously. No one at our school had ever before received a grant from Mr. Soros’s foundation. Plus, as luck would have it, Ellen, our benefactrice at the Open Society Institute, happened to be very good friends with the University’s new president, Donna Shalala. President Shalala, a former Peace Corps volunteer and a former Secretary of Health and Human Services, was on a mission to make us a great university. If we could win her over, we’d be poised for checkmate. What won the day, finally, was continuing support from the Green Family Foundation. The Green Family Foundation was established by a wealthy Miami businessman and former ambassador who gives a healthy portion of his income to charity every year. He also sits on the University of Miami’s Board of Trustees. Kimberly, his daughter, runs the foundation. Her faintly counterculture appearance—she’s always dressed in peasant blouses and bell-bottom jeans—belies focus and good instincts, which she applies with a hands-on approach to the family’s charity. I had met her at Barth’s office in an introductory meeting arranged by the Development Office. In attendance were several wealthy women, most of whom were only mildly interested in what we were doing in Haiti. Kimberly, on the other hand, immediately saw the potential to do something special there. Her foundation was focusing on AIDS in children. It had already built a wing for chil-

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti dren with AIDS at a hospital in New York City and was about to make a major commitment to our Department of Pediatrics Division of Infectious Diseases. At the meeting I suggested she broaden her scope to include all infectious diseases that were killing children in countries like Haiti and invited her to come with Medishare on our next trip, to see what we were doing in Thomonde and Cap Haitien. Kimberly instantly fell in love with Haiti. She met Paul in Cange, and our wonderful Thomondois welcomed her as if she were long-lost family. She witnessed firsthand our students, faculty, and their health fairs. She bought into Medishare’s vision of community health and community development in Thomonde. Her foundation then funded our community health program in Thomonde and produced a Medishare promotional video and a documentary on Haiti and its health needs to help raise funds for our project. Fortunately, Kimberly’s father had picked up on the tension between Medishare and our school. He volunteered to fund a trip to Haiti to see what Medishare and his foundation were doing firsthand. Guests would include President Shalala and the dean. In effect, he had made the dean an offer he could not refuse. “I’m not happy about this trip,” groused the dean during a preparatory meeting about two weeks before our departure. “It’s too much a public relations thing. The president loves that sort of thing—I hate it.” Barth, Michel, and I were taken aback by his comment, looked at each other and then at the dean. Perhaps we had overplayed our hand. For myself I saw this as another example of the curse afflicting the school’s administration—the same curse of cautiousness and conformity that had led to Joseph’s expulsion. “It won’t be political,” I promised. “We’ll be out in the countryside, with the people, not the politicians. We’ll set up some patients for you to see.” After the meeting Michel confided that he thought it was a good idea to let the dean see a few patients. “He’s in such a cage d’or,” exclaimed Michel. “He never gets to

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti University of Miami’s President Donna Shalala is welcomed in Cange. see patients anymore. His whole world bounces from one financial crisis to the next. Don’t worry, Art. The trip to Haiti will do him good!” The charter plane from Miami to Port-au-Prince was an hour and a half late. I later discovered it was missing a life raft and had to fly to Palm Beach to retrieve one before it could depart from Miami. My patience was tested as I waited on the observation deck of Aeroport International. Since first proposed by Ambassador Green, the entourage had grown to include Kimberly, President Shalala, the dean, Barth, Ellen, the dean of the School of Nursing, Michel, and another prominent Haitian-American physician, Rudy. Medishare’s executive director (also named Ellen), André, and I had gone down in advance to make sure everything was in order. The itinerary included helicopter rides to Cange and Thomonde, a reception in Port-au-Prince, and a visit to our residency program in Cap Haitien. Those of us on the observation deck waived as each member of the entourage deplaned. Thank goodness, they’re here now. Haiti, cast your magic spell, I thought, the same kind you cast on me nine years

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti ago. A reverse zombie curse—one that will liberate rather than enslave, enliven rather than zombify. We boarded two prearranged helicopters. I climbed into the smaller one with the president, Kimberly, and a few others, while the dean and everyone else climbed into a larger, open, Vietnam-era chopper. After the crew secured everyone in their seats, we slowly, imperceptibly lifted off the tarmac. It was a clear morning with unlimited visibility. Shortly after takeoff, the president nodded off. She must have gotten up at 4:00 a.m. Not the kind of spell I had hoped for, I thought. Looking over to the other helicopter, though, I could see the dean leaning out, peering intently at the countryside below. We had to pass over two mountain ranges and the Artibonite River valley to get to our first stop, Paul’s hospital in Cange. A trip that takes us three hours by car took only 30 minutes. Everywhere below us were the small plots of land and tiny homes connected by the footpaths that define rural Haiti. I nudged the president as we crossed Lac Péligre, the lake created by the dam made so infamous by Paul’s writings. From the air, Zanmi Lasante has a castlelike appearance. The helicopters made a seemingly miraculous descent to land side by side in the hospital’s courtyard. We disembarked, made introductions and were greeted by the Cange brass band, flowers for the president, and a large University of Miami banner that brought surprised grins to everyone’s faces. School children seemed to be everywhere, smiling, waving, singing, and lilting “Bonjour.” We met with the medical staff and took an abbreviated tour of the hospital. We wanted the president and dean to see what might be possible when a great university partners with a charitable foundation and a community in need. “See what Harvard did!” I deadpanned. “They only have a five-year head start on us!” We then climbed back into the helicopters for the short trip to Thomonde. Thomonde turned out in force to greet us, waiting patiently as we landed on the soccer field next to the national school. The crowd spilled out of the grandstand built in our honor and encircled the

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti sidelines. Delva was our official greeter, resplendent in a freshly pressed long-sleeved white shirt and a red-patterned tie. Signs and banners on the main street also welcomed us as we made our way to the dispensary and day hospital that Medishare had renovated two years before. Hundreds of patients waited there—to see not us but the Haitian doctor Medishare supported. It was a typical “day in the life” of the clinic since Medishare brought health care back to Thomonde: women receiving prenatal care and family planning, children with infections, old folks with innumerable afflictions. Our “day hospital,” originally intended as a triage station for patients who might need to go to Cange, was obsolete and overwhelmed the day it opened. One of our hopes for the trip was to generate interest in building a real hospital and a larger clinic on land donated by Thomonde. Both the president and the dean were moved by the obvious suffering of the eight patients in the day hospital. We had only six beds, so two patients were resting on mats on the floor. I introduced the dean to one young patient, who was swollen almost beyond recognition, a condition caused when the kidneys leak protein. “This is a cascade of catastrophes, John,” I said to the dean, after I explained to the patient in Creole why we were visiting. “What do you mean?” “It most likely started with a mosquito bite.” “A mosquito bite?” The dean looked puzzled. “Yes. Lots of mosquito bites here, as there’s no mosquito control program. And the kids scratch them and inoculate strep under the skin, which leads to cellulitis and impetigo. Some of the strep are so-called nephritogenic strains and that leads to post-streptococcal glomerulonephritis, nephrotic syndrome, and kidney failure.” The dean gave the patient a silent look of empathy and compassion. As we were leaving the dispensary he said to me, “I want to come back in the spring and just see patients.” “That would be great, John!” I responded. “You have to come

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti here and see it to truly understand the need and the difference we can make.” He put his hand on my shoulder: “You’re right. You have to see it to understand!” Haiti, the land of contrasts, was working its miracles. A minor miracle came at our next stop—a plot of land and a shell of a building on which we hoped to build a new hospital and clinic for Thomonde. After Delva explained what we hoped to accomplish, the president spoke spontaneously about the commitment the university would make to help. I listened incredulously, my hopes and dreams for Thomonde expressed by the president of the university. It was as if my words were coming out of her mouth! For the rest of the visit to Thomonde she alternated between praising our health care workers and brainstorming with various members of the entourage as to how we could get more students and faculty and other schools involved, and how we could write grants and raise funds. Of course, buy-in by the school and university would be a hollow victory if we weren’t also winning the war for the health of Thomonde. We stopped at our guest house as Marie was wrapping up the final day of the Thomonde census. Marie is a University of Thomonde’s community health workers.

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Miami nurse who used to work for Margaret as an AIDS research nurse. After hearing about our program, she decided to give up her work in Miami and return to Haiti as the in-country coordinator of the Green Family Foundation Initiative. With her guidance, our small army of accompagnateurs (community health workers) had visited every home in the district and cataloged each family’s health issues. This gave us, for the first time, accurate information on all the health problems in the commune. In the process, our accompagnateurs established a direct, personal connection with every family in Thomonde. What seemed like an impossible task had been made simple: Fifty community health workers serving 50,000 people meant that each worker served 1,000 people. Since the average Haitian family had five children, that meant each worker was responsible for fewer than 200 households—a remarkably manageable number. The president asked if there were any issues with the traditional healers. “Not at all,” Marie explained. “First, everyone knows everyone else. We’re all friends. Second, we had classes and seminars that included, in addition to the community health workers, the fanm saj, dokte fè, bokars, and mambos. So everyone sorted out who was responsible for what, and we refer patients to each other. For example, if a patient is lovesick, they’d be referred to the mambo. Fever and weight loss—that’s our province.” Next, we all trudged down a footpath to the house of Sonson. Sonson, his wife Charitable, and their seven children were all enrolled in our direct observed therapy program. When diagnosed with tuberculosis six months before, Charitable was wasted and too weak to work—a zombie, if you will. Sonson practically said as much. In discussions with his neighbor, Isoni, he attributed his family’s misfortunes to a curse placed on them by an enemy who wanted their possessions when they were all dead. Isoni was more than a neighbor, however. She was also one of our accompagnateurs. Slowly, over time, in the course of daily con-

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti The University of Miami team visits Sonson at his home. versations and visits, Isoni convinced Sonson that, in Charitable’s case, the Voodoo charms weren’t working. What did they have to lose by consulting the Medishare doctor? By that time, Charitable was too weak to walk and Sonson was too weak to carry her. Fortunately, a neighbor lent them his mule to make the one-mile journey to our clinic. Now, thanks to the daily visits of our health workers, he and his family were healthy again. He was working in his fields. His children were back in school. It seemed the curse had been reversed. While I must relate that I’ve never actually seen a real zombie in Haiti, I know several credible Haitian doctors who do believe they exist. Personally, I’m skeptical. If zombies do exist, it’s probably a rare occurrence for a curse to actually be placed. Just the threat of one assures conformity to society’s norms. But I’ve probably seen thousands of patients, just like Sonson, who, in searching for meaning in their fate, thought a curse had been placed on them. Treatment gives hope, and hope is the antidote—“Lespwa fè viv!” (“Hope makes us live!”).

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti We now have hundreds of patients like Sonson in Thomonde under treatment or who have completed treatment for tuberculosis and AIDS. After two decades of being outsmarted by a small bundle of nucleic acid and a protein coat, we’re finally figuring out how to get the upper hand. The people of Thomonde, this most improbable place, have shown the way. As our guest house was now serving as headquarters for the community health workers and as a residence for Marie, Delva, on his own initiative, had started a new guest house. When finished, it will accommodate 38 people, two per room, each room with a shower and toilet. Delva even included a courtyard and fountain in the design. Nimi, who led the group of women who did all the cooking and cleaning during our visits, had prepared a cornucopia of Creole delights for our lunch—macaroni and cheese pie, piklis (a spicy coleslaw), plantains, rice with beans, a beet salad, and more. The dean, the president, and the rest of the entourage filled their plates and marveled at the skills of Nimi and her crew. While everyone was eating, Delva and I slipped away to a quiet corner. Sitting side by side, we each sipped a Prestige, the Haitian national beer. We congratulated each other on our achievement: “Enkwayab, Delva. Prezidan ak dwayen Inivèsite Miami isit nan Thomonde. Vrèman, lwa ou-yo travay pou nou jodi-a!” (“Amazing, Delva. The president and dean of the University of Miami here in Thomonde. You sure have the spirits working for you today!”). Delva and I were holding hands. In Haiti you can hold the hand of a friend of the same sex. It’s simply a symbol of friendship. We continued our discussion in Creole. “What do we do next, Dr. Fournier?” “We’ll have a hospital and a new dispensary. Maybe four or five doctors and eight or nine nurses. I’d like to see Thomonde as a rural training center, a place where doctors can learn to work with nurses and community health workers. Your new guest house would be perfect.” “The University of Thomonde!”

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti “We could do that,” said Delva. “Good idea!” “So, which Lwa did you pray to to get Medishare to Thomonde?” I asked with a knowing smile. Delva returned a smile of his own. “Dr. Fournier, do you even have to ask?” “My guess would be Damballah, but I really need to know. You never know when I might need some help!” The helicopter ride back to Port-au-Prince was the most visually beautiful experience in my life. The Artibonite shone as a silver ribbon stretching to the horizon. The setting sun illuminated the hills and mountains in russet and gold. They in turn cast gray-green shadows across the valleys and plains. Waves of gold and shadow—a metaphor for Haiti, land of contrasts. Beauty and misery, slavery and freedom, death and resurrection. What more could one ask for from a country?