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Bicentennial

THE YEAR 2004 WAS SUPPOSED to be a festival year in Haiti—its bicentennial, marking 200 years since its independence from France. The year didn’t turn out that way, however. In the spring of 2004, the U.S. media presented the growing rebellion in a favorable light and painted the Haitian government under Aristide as a “failed state,” incompetent at best, corrupt and evil at worst. Aristide, for his part, seemed to be sleepwalking through the crisis. I wondered how many of his nine political lives he had left. Perhaps someone put a zombie curse on him, I thought. Certainly he had made mistakes during his administration. I had become disillusioned with his political party, Lavalas, after Delva lost the Thomonde mayoral election. I had no empathy for the rebels, however. They were clearly mercenaries with a sordid past. Worse, the theatrical violence I had noticed early on as an integral part of the Haitian political landscape was no longer just for show. Lives were being lost.

Inexorably the rebels marched from the north and the central plateau toward Port-au-Prince. Resistance evaporated in the face of their advance, almost as if the whole rebellion were orchestrated on both sides. When Cap Haitien fell under rebel control, services at our family practice clinic were disrupted for three days. In the Cen-



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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Bicentennial THE YEAR 2004 WAS SUPPOSED to be a festival year in Haiti—its bicentennial, marking 200 years since its independence from France. The year didn’t turn out that way, however. In the spring of 2004, the U.S. media presented the growing rebellion in a favorable light and painted the Haitian government under Aristide as a “failed state,” incompetent at best, corrupt and evil at worst. Aristide, for his part, seemed to be sleepwalking through the crisis. I wondered how many of his nine political lives he had left. Perhaps someone put a zombie curse on him, I thought. Certainly he had made mistakes during his administration. I had become disillusioned with his political party, Lavalas, after Delva lost the Thomonde mayoral election. I had no empathy for the rebels, however. They were clearly mercenaries with a sordid past. Worse, the theatrical violence I had noticed early on as an integral part of the Haitian political landscape was no longer just for show. Lives were being lost. Inexorably the rebels marched from the north and the central plateau toward Port-au-Prince. Resistance evaporated in the face of their advance, almost as if the whole rebellion were orchestrated on both sides. When Cap Haitien fell under rebel control, services at our family practice clinic were disrupted for three days. In the Cen-

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti tral Plateau our ambulance was “borrowed” by rebel troops three times. Each time, thanks to the consummate negotiating skills of Delva, it was located and returned to Thomonde. I was shocked to see a picture in the Miami Herald of rebels escorting Red Cross troops through Gönaives. The article talked of the “humanitarian crisis” developing in the north as a result of the roads being cut by the rebels and the inability of the Red Cross to deliver emergency food relief. The rebels had let them through in exchange, it seems, for a major photo opportunity. I drafted a protest e-mail to the Red Cross and received a polite letter back, explaining how they could not be effective if they didn’t remain neutral. Meanwhile, my Haitian-American friends were advising me to give it up. “The handwriting is on the wall, Art. The Haitian elite, the U.S. Embassy, and the media are all over Aristide. Remember, after he is gone, you still want to be able to function in the country,” they pleaded. We were forced to cancel our spring volunteer trip. Communication with Thomonde was sporadic. Marie was marooned in Port-au-Prince, our e-mail was down, and Delva could only occasionally get to the capital to send us phone messages. Fortunately, our Haitian infrastructure held together. The hospital in Cange never shut down. The Thomondois protected our guest house and clinic from looting and vandalism. Medical service interruptions were minimal. Through it all, our community health workers slogged it out, assuring that the mundane miracle of direct observed therapy continued. Eventually, a small contingent of U.S. marines landed. A few days later the United States and France declared they had no confidence in Aristide and, in the middle of the night, escorted him out of the country. He later claimed he was “kidnapped” by U.S. forces. The bizarre history of the relationship between Haiti and the United States had taken a new turn. When a “caretaker” Haitian-American prime minister was flown in from Boca Raton, Florida, he hailed the rebels as “freedom fighters.”

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti A charcoal market, Cap Haitien. After four months of headlines, Haiti’s 15 minutes of fame ended for a while. The U.S. public and media turned their attention to the presidential campaign and the conflict in Iraq. On the ground in Haiti, things in Port-au-Prince were as bad as or worse than when Medishare first came 10 years earlier. There was no electricity, there were huge piles of uncollected garbage, there was political violence and the treasury was bankrupt. United Nations peacekeeping forces seemed reluctant to intervene in the simmering feud between polarized political factions, sure to erupt into violence again the next time an election is attempted. The political turmoil of the winter and spring was followed by natural disasters during the rainy season. In May, flooding killed hundreds in the towns of Jimani and Fonds Verrettes. In September, floods spurned by tropical storm Jeanne killed thousands and left hundreds of thousands of people homeless in the region around the city of Gonaïves.

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti The international peacekeeping force and international relief agencies seemed totally unprepared. The United States pledged a paltry $50,000 for humanitarian relief but then increased its pledge to $2 million after it was shamed by more substantive contributions by Venezuela and Cuba. In reality, little aid from any source trickled down to those in need. People who had gone without food and water for days were scattered from food distribution centers by rifle shots and tear gas. Marie, Delva, our doctors in Thomonde, and our partners in Cange packed truck loads of medicines and drove them into the disaster area, donating them to the agencies—CARE and UNICEF—responsible for recovery. “It was worse than you could possibly imagine,” Marie told me. “The stench of death was everywhere. But almost as bad—depressing, really—was how disorganized the international relief effort was. No one knew what the others were doing; no one took charge. Women and children were walking around in a state of shock.” There are those who believe that events such as the floods of Gonaïves are proof that Haiti is, indeed, cursed. There is a legend in Haiti that Toussaint L’Ouverture made a pact with the devil to drive out the French and that all of Haiti’s woes spring from that Mephistophelian source. From a theological perspective, the “Haiti is cursed” theory should not be dismissed without careful deliberation. The recurrent flash flooding in Haiti is the result of deforestation of the country. Many Haitians believe that Lwa, the Voodoo spirits, live in the trees, particularly mapou and mahogany. Being totally dependent on charcoal for fuel, the Haitian peasants are forced to choose between survival and the wrath of the gods. In truth the last secret of the zombie curse is that Haiti’s curses are not supernatural in origin at all, but rather the consequences of the actions of men. I recalled my conversation with the foundress of the Haiti Baptist Mission concerning the mudslides caused by tropical storm Gordon 10 years before. Since then a decade had passed and nothing had been done to address the root causes of this kind of disaster. Certainly the cutting of trees for charcoal in the most densely

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti populated country in the Western Hemisphere established conditions that in a major storm like Jeanne could sweep away all in its path. But here, once again, blaming the victim makes it easy for us to walk away. It’s the peasants’ fault for cutting down the trees, we assume. The real cause of the death and despair of the floods is the same as the AIDS epidemic—poverty and its consequences. Poverty drove the Haitian peasants to try to terrace and till every inch of marginal farmland. Poverty continues to drive them to use the cheapest fuel possible, charcoal, knowing full well they are killing their country in the process. If one probes deeper, things become even more complicated. Gonaïves lies on a flat plain at the mouth of the Artibonite River. The Artibonite, Haiti’s largest river, starts at the infamous dam at Lac Péligre. Rumor has it that the night of the storm, the damkeepers, fearing the dam might burst, opened its flood gates, dumping billions of gallons of water down the valley toward the sea. Canals intended to facilitate drainage at the mouth of the river had long been neglected. In practically an instant, man and nature had conspired to transform 250,000 people from a state of decent poverty to one of despair. Worldwide, in 2004 the AIDS epidemic showed no signs of abating. International agencies and giant foundations gave millions of dollars to make AIDS drugs available at lower costs. While this was undoubtedly a good thing, little was being done to address the root cause—the exploitation of the poor, particularly women. Until the world wakes up to that reality, that little clump of nucleic acid will continue to outsmart us. In fact, if an evil scientist or dictator were scheming to design a plan to spread AIDS around the world as a weapon of mass destruction, he couldn’t come up with a better plan than the way, in the United States and the developing world, we deal with issues surrounding poverty. Foremost is the exploitation of women—always poorer than their male counterparts, dominated by them, kept socially and politically inferior, and forced into such survival choices as

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti prostitution or early marriage. Then there’s the problem of political violence—sexual coercion associated with armies, rebels, and police. Our corrections institutions long ago abandoned any attempt at rehabilitation. They have become revolving doors of drug users, sex offenders, the homeless, and the mentally ill. Prison authorities turn a blind eye to sex, coerced and uncoerced. Some in society even see the rape that invariably occurs in prisons as part of the punishment due a prisoner who’s committed a crime. Lack of access to care, the cost of medicines, and inadequate public health and public education are fueling the epidemic. Even immigration policies have helped spread the disease, breaking up stable relationships as one partner or the other is allowed to emigrate legally or flees to work as an illegal alien. In Miami the war against AIDS has been a virtual stalemate for several years. Newer AIDS medicines dropped the death rates among known AIDS patients for a while, but problems like drug resistance and serious side effects have surfaced. Meanwhile, the number of new cases keeps rising. This should not be surprising. First, the programs funded to care for the poor with HIV emphasize expensive medical treatment in the advanced stages of the disease. There is little attention to prevention or primary care. More importantly, in a country that has yet to acknowledge health care as a right, both the programs and the people who provide the care find it impossible to escape the “zombie curse” of prejudice, blame, and conventional thinking. For example, a young working mother of two recently walked into our private practice complaining of two weeks of the flu. As soon as I saw her, it was clear she was desperately ill with pneumonia associated with AIDS. As I delved further, I discovered the following: She learned that she had AIDS while pregnant with her second child and had been on highly active antiretroviral therapy until she started working. At that point her Medicaid was cut off. She made too much money! To make matters worse, she was told by her employer that she’d have no health insurance during her probationary

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti period. When she finally did qualify for insurance she was denied coverage for AIDS treatment because her disease was a preexisting condition. During the time she was without insurance and without treatment, her immune system deteriorated from a level robust enough to fight off opportunistic infections to a level almost incompatible with life. She almost died and her children were almost orphaned because she found a job and therefore lost her insurance! The cost of her totally preventable hospitalization was probably 10 times the cost of maintaining her insurance. Ironically, in 2004, at least with regard to the AIDS epidemic, things in Haiti were a little better. Countrywide, the prevalence had actually fallen a bit, a small blessing that’s probably attributable to a falloff in exploitative sexual tourism, new programs in public education, and the superhuman efforts of Paul Farmer, Bill Pape, and others engaged in the AIDS arena. Haiti is a recipient of funds from the presidential initiative to fight AIDS. Wisely, the people at the U.S. Agency for International Development who manage this program in Haiti realize that the war against AIDS can’t be fought in a vacuum. They’ve designed a countrywide multifaceted program that is creating a general health care infrastructure with the capacity for AIDS care, rather than trying to treat only AIDS. Programs in prevention and nutrition as well as AIDS care and treatment are being implemented. Our family medicine training program is playing a role in this effort, not only through its services to patients in Cap Haitien but also by training the next generation of Haitian doctors to be competent in all aspects of AIDS care. In 2004, over 1,000 patients with AIDS joined the 15,000 patients already receiving comprehensive health care services from our residents and faculty in Cap Haitien. However, if civil war erupts, these modest gains will be rapidly reversed by the rape, coercion, disruption of services, and worsening poverty inevitably associated with war. Actually, even in the absence of overt civil war, the virus is mounting a counteroffensive. Skirmishes between pro- and anti-Aristide forces in the slums of Port-au-Prince have driven the market

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Sonson’s son after completing Direct Observed Therapy. Photo by Wassim Serhan. women who used to work there up into the relative safety of Petionville. An estimated 6,000 people are now “working homeless,” living in the streets that serve as the outdoor markets of Petionville. It’s the “Petri dish theory” revisited, with every bodily function performed in the streets. Haitians of all walks of life, all levels of society, refer to this sea of humanity as “ti-Fallujah.” Miraculously, in Thomonde incredible progress has been made, despite Haiti’s precarious political situation. Paul received a large grant from the Global Fund to Fight AIDS, Tuberculosis, and Malaria, which has made medicines available to all and allowed us to expand our team of health workers. With treatment and a simple but effective delivery system (our community health care workers) the stigma of AIDS and tuberculosis is dissolving. Over 400 patients have been enrolled in our direct observed therapy program. To date, not one has died. There are two secrets to our success in Thomonde.

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Thomonde’s community health nurse. First, we’ve trained Thomondois to be peer educators, counselors, and therapists. This has enabled patients to care for themselves and to take an active role in their own health, with the health care workers serving as a safety net if things don’t go according to plan. My colleagues in Miami think I’m joking when I tell them we now have a better and fairer health care system for the poor in Thomonde than we do in Miami, but I’m actually serious when I say this. How ironic that Thomonde—one of the poorest regions of the poorest country in the hemisphere—has a more effective model of care than most of the United States. In the States, frequently those who need health care the most get it the least and those who need it the least get it the most. People of all socioeconomic strata take health care for granted; they just want to take a pill and to have their problems go away. Paradoxically, many of our health problems here in the States are the by-product of our affluence—rampant obesity, even among children, along with its complications, diabetes, hyperten-

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti sion, and heart disease. Even the poor in this country suffer from a relative affluence. For examples, one need look no further than the popularity of cheap fast food and its contribution to the epidemic obesity or the use of cheap crack cocaine and its role in the spread of AIDS. In Creole there is no verb equivalent to the French avoir, “to have.” The closest equivalent is ginyen, meaning to gain or earn. So in Thomonde the people take nothing for granted; one doesn’t “have” good health, one earns it. A trip to Thomonde will quickly shatter stereotypes about the poor—that the poor are lazy or dumb or lack family values. The Thomondois as a group are industrious and eager for knowledge about their health. Their entire lives are family centered—materially, in the sense that life evolves around the inherited family plot of land; but also spiritually—children, old folks, and ancestors are all revered. They’re also community centered. There’s not only a knowledge of and concern for all of one’s neighbors but also a communal way of getting things done, whether it’s building a house or clearing a field. These are traditions that started in the days of slavery. In this milieu it has been much easier to build a health care system than one might think. To Medishare’s credit, we haven’t just thought about health—we’ve supported education, nutrition, and, most importantly, created meaningful jobs, perhaps the most effective way to fight the infectious diseases that afflict the poor. The uplifting of socioeconomic status that Medishare has brought to Thomonde is the second secret of our success. We’ve created a rural middle class in the health care sector. Our community health care workers cost us about $100 per month—a pittance by U.S. standards, but a decent salary in a country with an average per capita income of $200 per year. These funds have percolated throughout the commune, contributing to the well-being and elevating the standard of living and quality of life of even the poorest Thomonde peasant. Medishare is using health as a fulcrum to leverage community development. Ellen, Medishare’s executive director, has organized the

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti commune and provided the resources to produce a protein-enriched powder that, after just adding water and boiling, becomes a nutritious, culturally accepted porridge. Called Akamil, this porridge will not only treat the malnourished children of Thomonde but will also be sold for a modest profit in other communities in Haiti. Impressed with the progress Medishare has initiated in Thomonde, another foundation, Fonkoze, has started a program in micro-loans, to further reduce the level of poverty. Totally unexpected developments are happening spontaneously, thanks to Medishare’s investment in the people of Thomonde. Nimi, our cook, is one example. She saved the money we pay her to cook for the Medishare teams and opened a school for cooking and baking. Evidently, there’s a market for this, particularly the baking skills. Cakes are needed to celebrate all major life events, and it’s no small feat to be able to bake a cake over an open charcoal stove. Nimi has now graduated two classes of chefs, who study with her for a full year and receive a certificate upon graduation. In addition to sharing her culinary secrets, Nimi teaches nutrition and food hygiene, knowledge and skills she learned from Medishare. These are critical advances for public health in rural Haiti. As Medishare celebrates its 10th anniversary, it has far exceeded my original expectations. Every day now, starting at 6:00 a.m., Nimi and her crew brew several pots of Haitian coffee, scramble eggs, and cook Haitian spaghetti to send off our 50 community health workers on their daily rounds. The workers pack their coolers with ice, so their vaccines won’t spoil, and stuff their satchels with Direct Observed Therapy forms and precious medicines. By 7:00 a.m. they set off—some on foot, some by horse, and some by motorcycle—to the farthest reaches of the commune, full of zeal and enthusiasm for their work and a loving concern for their patients that I rarely see anymore in America. In addition to treating AIDS and tuberculosis, our workers have launched an immunization campaign. In 2002, Thomonde had the worst immunization rates in Haiti. Now, 98 percent of the children

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti have been immunized. In 2005 the Pan American Health Organization plans to finally begin a campaign to eradicate rubella from Haiti. Thomonde will be one of the few rural communities with an infrastructure to implement the project. By 7:30 a.m. the school children head for class, replete with book bags and color-coded uniforms. If they show signs of malnutrition, they’ll receive Akamil at school, in exchange for their parents keeping them enrolled. Pregnant women and patients on Direct Observed Therapy also get Akamil, flavored with cinnamon and vanilla. The dispensary opens at 9:00. On the average, 200 patients pass through its doors each day. Meanwhile, before dawn, while the lycee students up in Cap Haitien are pacing and reciting their devwa (“homework”), our family medicine residents are reviewing their admissions from the night before in anticipation of attending rounds. Patients line up each day at the family practice center for immunization and family planning. The program is now sustained through funding from the U.S. Agency for International Development. Haiti’s ministry of health is encouraging us to expand training of family doctors, and we’re hoping to open a second program based in Thomonde as soon as we’ve completed construction of a new hospital and clinic. Blessed with knowledgeable and enthusiastic Haitian partners, day by day, we’re making a difference. Thanks to the visit by the president and the dean, the issues between Medishare and the University of Miami are now history. The dean will be sending a team of eye doctors and students to give eye care to the people of Cange and Thomonde on a regular basis. President Shalala is helping us connect with some major international donors. With their help, and the help of a prominent Miami family, the Jay W. Weiss Center for Social Medicine and Health Inequality has been founded at the University of Miami-Miller School of Medicine. Almost 30 faculty members have signed on, with a variety of projects planned at home and abroad to help those in need. Our work in Haiti serves as the center’s flagship, leading the way. Working with Paul Farmer, the center will train a special group

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti of residents in family medicine, pediatrics, and internal medicine in the skills necessary to be effective in international health—teaching them not just how to treat the diseases associated with poverty but more importantly how to attack its root causes. More than 100 first-year medical students—that’s two-thirds of the class—have signed up to volunteer for Project Medishare. They are busily planning, along with our 50 second-year students, this year’s health fairs. Over the years more than 500 medical students, doctors, and nurses have contributed to Haiti’s health under Medishare’s umbrella. Other medical schools—notably, George Washington and Northwestern—are partnering with us to expand services in the communities around Thomonde. Medishare’s collaboration with Paul’s charity Zanmi Lasante (Partners in Health) has allowed us to expand our community health workers and created an environment in which the Haitian doctors and nurses we’ve hired for Thomonde have the backup and support they need. In turn, Paul has hired one of the graduates of our family medicine training program to work in Cange. “Send me more,” he says, when I ask him how our doctor is doing. “He can do it all!” To date, we’ve graduated 12 doctors from our residency program. All but two are now working as family doctors in rural Haiti. We’ll be producing at least five Haitian family doctors per year and will hopefully increase that number to 10 in the near future. My still-unfulfilled dream is to start more training programs and link them to the training of nurses and community health workers. Thomonde, with its seasoned and skilled health care workers, with Marie (Medishare’s nurse), and Delva’s spacious new guest house would be an ideal training site, assuming we can raise the funds to build a new hospital and clinic. Medishare owes a great deal to Dr. Paul Farmer. The example he sets in terms of sacrifice, dedication, cultural competency, and solidarity with the people, plus his commitment to health as an issue of social justice and his unwillingness to accept a double standard of care for poor people is remarkable. Medishare, however, is now mak-

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti ing its own contributions to the evolving strategies to improve health care for the poor. Paul, in his writings, eloquently makes the point that effective treatment with unequal access to care is an injustice. Through our health fairs, patient education programs, immunization campaigns, and training program, we’ve extended Paul’s concept to include not just treatment but also screening, prevention, and primary care. Second, we steadfastly believe that, ultimately, through education, the torch must be passed to Haitian providers. During the past 10 years, my students and I have made over 100 trips to Haiti. Our project has expanded, and it is still growing today. Yes, we’ve experienced our share of scorching heat, torrential rains, political turmoil, flat tires, and mud holes. We’ve also had total strangers help us change those tires, pull us out of those mud holes, and shelter us from the tribulations that are part of daily life in one of the poorest countries in the world. In the early days, I frequently traveled alone. Now, I never lack for friends and companions. Invariably, the Haitian people have given much more to me—lessons of courage, patience, ingenuity, and mysticism—and countless opportunities to make a difference. More than unlocking the mysteries of Voodoo and the zombies, more than making my students and me better doctors, my experiences have shown me how to live a better life. “Ayiti te mete yon wanga sou mwen!” (“Haiti cast a spell on me!”).