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Angelik

March 2005. “NOT A GOOD SITE FOR A health fair,” murmured Ellen, Medishare’s executive director, as we climbed out of our trucks and descended down a barren ridge to the school at Croix Rondo (Rounded Cross). “Too much wind! Too much dust!”

The school was a large open cement platform with a few upright posts that supported a tin roof. At least we’d have some shade. Our health agents had tied ropes and sheets to some of these posts and squared off a corner with portable blackboards to provide one small area of privacy for prenatal care. The sheets billowed and popped in the wind like poorly trimmed spinnakers, adding to the noise created by the din of the crowd and the wind howling under the roof. There were only three trees on the otherwise barren ridge and little grass. There had been no rain in five months. From the ridge one could look out over what seemed like the entire Plateau Central, extending to the horizon. The trade winds, blowing from the northeast, raced across the plateau until they reached the ridge, scouring us with blasts of hot air, powder, and dust that peppered our skin, stung our eyes, and clogged our nostrils. Crowds had gathered in the sparse shade of the three trees where our health agents had set up



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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Angelik March 2005. “NOT A GOOD SITE FOR A health fair,” murmured Ellen, Medishare’s executive director, as we climbed out of our trucks and descended down a barren ridge to the school at Croix Rondo (Rounded Cross). “Too much wind! Too much dust!” The school was a large open cement platform with a few upright posts that supported a tin roof. At least we’d have some shade. Our health agents had tied ropes and sheets to some of these posts and squared off a corner with portable blackboards to provide one small area of privacy for prenatal care. The sheets billowed and popped in the wind like poorly trimmed spinnakers, adding to the noise created by the din of the crowd and the wind howling under the roof. There were only three trees on the otherwise barren ridge and little grass. There had been no rain in five months. From the ridge one could look out over what seemed like the entire Plateau Central, extending to the horizon. The trade winds, blowing from the northeast, raced across the plateau until they reached the ridge, scouring us with blasts of hot air, powder, and dust that peppered our skin, stung our eyes, and clogged our nostrils. Crowds had gathered in the sparse shade of the three trees where our health agents had set up

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti tables to register patients in advance. I estimated 300 patients were waiting to see us. It was going to be a long day. My team included several returning Medishare veterans, most notably Joseph, about to finish his second year in our family medicine residency program; Rachel, a graduating senior who had come on three prior trips; and Rick, who had come four times before and was now an emergency medicine resident. Nine enthusiastic medical students, a volunteer nurse, and four Haitian health workers rounded out the group. The health fair the day before at Boucantis, an even more desolate and remote part of the commune, had gone very well. Construction of the new hospital/clinic complex in Thomonde was proceeding more quickly than anticipated, and we had just received some good news about funding for our nutrition program. Considering all this, I should have been in better spirits. But our trip to Thomonde had been delayed a day by violence. On the day we arrived, the United Nations forces had engaged in skirmishes with former rebels in Petit Goave, with casualities on both sides, and demonstrations had erupted in Terrier Rouge. Terrier Rouge straddled our usual route up Morne Kabrit on Route Nationale 3. So after a night in Petionville, we were forced to take an alternate route to Thomonde—an exhausting eight-hour journey through St. Marc and the Artibonite Valley. Plus, I had a mild knee injury from a previous trip, which was aggravated by long car trips or standing for long periods of time. Between the ride up, the ride out to Boucantis the day before, five hours on my feet there, and a one-hour ride to Croix Rondo that morning, my knee was already throbbing like a toothache. The pain, fatigue, dust, and noise combined to create an unusual sense of foreboding. The boundaries of the commune of Thomonde were defined politically, not geographically. To get to Croix Rondo, our convoy had to first ascend and then descend the Thomonde caldera’s volcanic lip, cross a river, climb back up onto the central plateau, turn off a bad road onto a glorified footpath, and bounce and pitch for another half hour to the ridge where we would hold our fair. I esti-

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti mated it would take four hours to get from there to our clinic in Thomonde on foot and two hours by mule. Because of its isolation, Croix Rondo had yet to have a health fair. Five months without rain had made even the usually oasis-like Thomonde basin look dry. On the central plateau, on the other side of the Thomonde rim, things were positively parched. In over 100 visits, we had witnessed floods, revolution, and the effects of crushing poverty, but I was mentally unprepared for drought and its sister scourge, famine. The media, preoccupied as always with the politics and violence of Port-au-Prince, had never mentioned either. More than disease, rebellion, or flooding, crop failures associated with drought could easily reverse the progress we were making in Thomonde. And unlike disease, I had no answer for it. It was not as if we could treat thirst with antibiotics! We would see more sickness, particularly among the children, at Croix Rondo than we’d seen in Thomonde proper. Several children with severe malnutrition stood out in the crowd, easily identified by their telltale red hair and swollen bellies. Because it was Croix Rondo’s first health fair, it took us longer than usual to get set up and organized. Pregnant women were seated outside the billowing sheets that defined the prenatal care station. Rick and some students arranged some handmade school benches into a child care section next to them, and Joseph structured a similar station for the sick adults at the far corner of the school. As soon as they were registered, our patients climbed about a hundred yards up from the shade of the three trees and waited patiently in the shade of the north side of the school to be called to a station. Most were dressed in their Sunday finest, sadly powdered with dust on the side that faced the wind. I floated from station to station, encouraging my students to be thorough but efficient, talking to the patients in Creole, and writing brief notes on their charts to hasten the process of evaluation and referral. By 11:30 the health fair was in high gear. “Reynaud!” I yelled at the top of my lungs, attempting to get the

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti attention of our health agent. “Vini isi!” (“Come here!”). “Nou genyen lòt timounn ak tibèkiloz!” (“We’ve got another child with tuberculosis!”). Kea, a first-year student, had just correctly diagnosed tuberculosis in a five-year-old boy by feeling the telltale matted lymph nodes in the back of the child’s neck. It was our third case of TB that morning. “This particular way that TB presents is called ‘scrofula,’” I explained to Kea, while congratulating her on her clinical acumen. Kea burst into a radiant smile and then a sigh. “Gee, I feel like a doctor!” she gushed. “Yes, before Medishare, that child and countless like him would have died. Now Reynaud will make sure that he’s on treatment no later than tomorrow. His whole family will be tested. You’ve made a difference. It’s a great feeling. Enjoy it, just for a moment, before you see your next patient,” I counseled. My optimism was starting to return. In addition to the three children with tuberculosis, we had found one child with pneumonia. All would likely have died had we not come to Croix Rondo that day. Plus, we found one boy with undescended testicles, an old man with cysts in his testicles related to elephantiasis, and an older woman with a large neck mass. These patients could all be helped by the surgical team that Medishare was sending down in June. Just then Rick touched my arm from behind to get my attention. “Dr. Fournier, I need you to see this child. Please tell me that what I’m seeing is not what I think it is.” “I’ll be right there, Rick. Let me just finish with Kea and Reynaud.” I joined Rick at his “kidscare” station a few minutes later. He spoke as softly as he could and still be heard above the wind and the crowd, “This is Angelik. She’s 9. Her mother brought her because she’s got marks on her genitalia. I think its HPV.” HPV is short for human papilloma virus—another smart virus—the one that causes cervical cancer. HPV in this particular anatomic location, in this child, could mean only one thing—sexual abuse. I picked Angelik up and carried her behind the sheets to the prenatal care station. Fortunately, the prenatal team was between patients and

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Young boys in Thomonde with their homemade “futbol.” Photo by Wassim Serhan. the examining table was empty. Rick and Angelik’s mother followed me. “The marks are a curse,” she whispered to me, careful that the other patients would not hear. Angelik was a beautiful child with dark, unblemished skin, large eyes, and neatly braided hair capped with little white beads. Her face, however, was frozen in fear. It was impossible to know whether her fear was caused by the trauma she might have experienced, the possibility that she was cursed, or all the attention she was getting from these funny-looking strangers. “Don’t be afraid and don’t be ashamed,” I whispered into her ear in Creole. “I need to look down here to see what these ‘marks’ are.” I gently positioned her on the table, bent her legs, and removed her panties. There was no mistaking the classic lesions of HPV that covered the top of Angelik’s vulva and extended down, in clusters, over her clitoris and inner lips. Rick, who had put on examining gloves, shined his penlight on her vagina. “There’s no hymen and the mucosa looks inflamed,” he murmured. I quickly peeked at where his light was shining and confirmed his findings.

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti “It’s a curse!” Angelik’s mom exclaimed again. The marks she was referring to are commonly known in English as “lover’s warts.” This seemed a particularly cruel appellation given the circumstances and I knew of no equivalent Creole translation. How could I explain this in terms that Angelik and her mother would understand? Having seen tens of thousands of them in my career, there was simply no alternative explanation. So there it was: the smoking gun! Ever since my first trip to Haiti, when Regine had stroked Ruth’s leg and asked for her wallet, I had recognized the relationship between the exploitation of women and children and the spread of sexually transmitted infections. I had written about it and spoken passionately about it. But seeing it, literally staring me in the face, shocked and startled me. Evil existed in the world, even in my beloved Thomonde. “Excuse me,” I said in both English and Creole. “She can get dressed now.” “Rick, I’ll be right back. We need a plan.” I exited the curtain and walked over to our trucks, in part to talk with Marie, our nurse coordinator, and in part to gather my thoughts. Marie was reclining in one of the seats, catching her breathing in front of the car’s airconditioner. Usually an inexhaustible bundle of energy, Marie had suffered an asthma attack, precipitated by the dust, forcing her to retreat to the relatively pure air of one of our cars. “I’ve got a little girl who’s been sexually abused,” I said solemnly. “What can we do?” Perhaps it was fatigue brought on by her attack, but Marie seemed oddly unsurprised by my news. It was as if, with all the health fairs we had been through together, it was only a matter of time before we had a patient like this. “We can tell the police, but they rarely intervene in cases like this. For all we know, they might even be the problem! The best thing is to have her mom bring her to see our nurse-midwife in Thomonde. At least she’s a woman and won’t add further to the fear and blame.” I returned to the health fair. Before speaking to Rick or Angelik’s mom, I locked in my eyes to the child’s eyes. For the first time in my

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti career I dropped all pretense of objectivity, that cold distancing mechanism I had used to protect myself from engagement with Regis, Marc, Previlus, Fanesse, and the others—the “hey, I’m sorry, but you’re the one with the disease” attitude that seems to afflict so many doctors. For a long silent moment we looked at each other without hierarchy, not as doctor and patient, adult and child, Haitian and American, but simply as two human beings, one suffering and one wanting only to help: “Nou renmen ou. Nou kapab ede ou, nou kapab retire mak-yo” (“We love you and we can help you. We can make the marks go away”), I repeated, three times, almost like a religious chant, as I held her jaw in my hand to keep her eyes focused on mine. By the third incantation I managed to elicit a soft smile. I returned her to her mother’s arms. Angelik’s mother was dressed in an orange-yellow blouse with shoulder pads and a flowered skirt. She looked about 35 years old, but her harsh countenance, probably reflecting both fear and concern for her daughter, may have made her appear older than she actually was. She knew exactly what I was thinking and half-heartedly repeated her assertion that the marks on her daughter were a curse. “It’s not a curse. It’s an infection, nothing more.” I responded. “We can get rid of it. Don’t blame yourself and don’t blame Angelik.” “Dakò,” she agreed. “I have to ask you some more questions. Are there boys in the house?” “No. She only has sisters,” she answered emphatically. “Could it have been her father?” I asked straightforwardly. She answered with an equally emphatic “No!” “Did Angelik say anything about who might have done this?” “No. She has not spoken in weeks.” “Well, she needs all of our love and you need to protect her. Make sure there’s another woman around when you go to the market. Bring her to see the nurse-midwife at Thomonde. A simple treatment will make the marks go away—a purple potion. (“Podophyllin!” I said as an aside to Rick). “When the marks are

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti gone, if you treat her as always, she should start talking again.” With that her countenance softened and she gathered up her things to leave. I took Angelik by the shoulders and stooped to kiss her on the forehead. “Bondye beni ou” (“God bless you”), I spoke as I engaged her eyes one more time. “Rick, I’ve already told Marie about this. Make sure that Reynaud knows and brings her to Thomonde tomorrow. She’s going to need tests for chlamydia, gonorrhea, syphilis, and HIV, in addition to the podophyllin treatment.” “What do you suppose happened and who did this to her?” asked Rick when they had gone. “We’ll never know,” I responded. “It’s possible she wasn’t raped but only molested. The role of digital intercourse in the transmission of HPV is poorly understood.” My wall of objectivity had reascended. I had become a professor again. “Your findings on penlight exam were ominous, though. I fear the worst. As to who did it, in the States, it would most likely be a family member or friend. Here, you can’t assume that. While it’s true that Haitian girls start having sex at a young age, it’s usually after puberty and consensually, as part of courtship. Remember, there’s a miniwar going on out there. We’re only a couple of miles from the Dominican border and both rebels and United Nations troops are combing these hills. Soldiers are notorious for taking advantage of the powerless and even the UN troops are not above suspicion. Did you read that article last week about rapes in the Congo? A child Angelik’s age would be pretty much on her own on the days when her mom was at market, particularly if she wasn’t in school. It may not have been directly forced sex; it may have been pseudoconsensual. There’s a drought here. Delva tells me the wells are going dry, and he’s had to truck in water! Angelik may have let someone have his way with her for something as basic as a drink of water. Let’s get back to work. We can talk about this more this evening.” By the time we arrived back at the guest house my knee was really throbbing. I asked Delva for some rum, which eased the throbbing and numbed my brain. “You didn’t tell me just how bad the

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti drought was, Delva,” I admonished. “It was brutal out there at Croix Rondo.” “I’m sorry, Dr. Fournier, but I did tell you. We’re lucky here in Thomonde. At least there’s still water in the river. But it’s like Croix Rondo throughout the Plateau Central,” replied Delva. “Remember, I told you we were trucking water to the outskirts of the district. You just had to see it with your own eyes.” I took a brief shower, being careful to conserve water and then took a nap before dinner. Rick did not bring up Angelik for discussion after dinner. Perhaps I had sufficiently addressed his questions or perhaps he felt her privacy had already been violated. The next morning I had to leave for a meeting in Port-au-Prince. As the truck rumbled past the dispensary, I peered into the shadows of the waiting area. It was too dark in the dispensary to discern individual faces, but I could clearly make out Angelik’s mom’s orange-yellow shirt with shoulder pads and her flowered skirt. A small girl’s form in a white communion dress and white hair beads also radiated from the darkness. Well, the system worked. The health worker got her here. She’ll see the nurse-midwife, I thought to myself, as the dust raised by my truck obscured them from view. It’s a start. Please, God, let her heal. Just the possibility of an innocent child trading sex for something as basic as water overwhelmed my consciousness. And send us rain! I thought, as we headed out of town. Then, remembering the Gonaives floods and the old admonition about being careful what you wish for, I added an addendum to my prayer—just not too much!