Donate NowDr. Jean William Pape is tall. He has even developed that generous stoop of very tall people who are self-conscious of shorter people, somehow finding a way to bring the face closer to those shorter than them. He is a fit looking man in his sixties with a graying neatly trimmed beard, and a receding shock of white hair. He is what is called in Haiti "grimo"—a lighter skinned person. A graduate of Columbia and Cornell universities, he has worked in Haiti for much of his career while maintaining strong effective links with universities in the United States and a faculty position at Cornell.
I had not expected as warm and friendly a man when we were guided into his offices in the GHESKIO compound in Port-au-Prince by his assistant, a lively former teacher, Madame Jadotte. GHESKIO is the organization Dr. Pape founded in 1982 to study the unusual incidence of Karposi's Sarcoma. It has been a leading center for the study and treatment of HIV/AIDS in the three decades since. Madame Jadotte had been the contact between us and Dr. Pape; the stringent expectations, the negotiation of time, the request for questions, and much else all suggested that this was going to be a formidable meeting with a man who is quite a legend in Haiti and around the world for his unquestionable success as an advocate for the treatment of HIV/AIDS and infectious diseases in Haiti.
Since the earthquake, Dr. Pape had been embroiled in a bit of a controversy about the new approach to HIV/AIDS in Haiti. At a conference in Vienna in July, some reports painted Pape as someone who was underplaying the serious impact of the earthquake on HIV/AIDS patients, and he was pitted against what were described as "grass roots activists" who mounted a protest in the middle of the conference demanding that the Haitian government and all the agencies working in Haiti develop a more comprehensive plan for HIV/AIDS. According to Dr. Marie Mercy Zevallos, a director of POZ SIDA (another leading non-profit on HIV/AIDS issues) and hardly someone who could be called an "activist," the government had failed to include a comprehensive plan for HIV/AIDS in its post-earthquake plans. But she, like Pape, is of the view that a broader view of general health improvement can only be good for HIV/AIDS. However, hers is a pragmatic position based on the reality that most international funding agencies are moving away from the focused approach to HIV AIDS or any other single condition. Pape, on the other hand, does not play up this change in international policy, and speaks with the kind of passion of one who believes that if there is such a change going on, it is a good one. But he is savvy enough to know that if changes are not made by the HIV/AIDS community in Haiti, future funding might be difficult to secure.
In reports from Vienna, Dr. Pape was quoted as expressing general optimism about the way things had gone for HIV patients after the earthquake. It was the kind of upbeat view that seemed to run counter to the concerns of many activists who argued that it was too early to speak and that there was growing evidence that the conditions were actually not very good for HIV/ AIDS sufferers, nor for the sustenance of the progress already made in HIV/AIDS in Haiti over the last ten years.
Dr. Pape, however, is clearly a man who, like almost every resident of Port-au-Prince, has been transformed in vision and action by the earthquake. During our off-camera conversation after the interview, what he had offered in measured, professorial tones during the interview came out in a flow of passion and deep concern, and reflected his visceral sense that what he wanted to do was try to somehow meet the emergency needs of the Haitian people who he said were living in the most abject conditions. He observed that he and his wife had seen some restaurants opening up near tent cities, and he was appalled by this. "How can you go to the restaurants and the people there are living in those conditions. You know. It is horrible. So that brings nightmares." He said he had no affiliations with any political party, and he said he found politics to be too dirty for him. But he also sought to give credit for some of the work done, indicating that the catastrophe would overwhelm any leader in any nation. At the end of the day, Dr. Pape worried that there might not be the will to do the work that needs to be done for the tent-city dwellers in Haiti. He felt that politicians had a vested interest in the maintenance of the tent cities because they represented a captive audience that could be used effectively during elections. He wondered what would happen once a new leader was in power. Would they forget the people?
Dr. Pape had seen my questions before the interview, and that may explain the clarity and uninterrupted stretch of reflection and commentary, and explanation of his position that characterized the interview. Above all, he struck me as a determined and focused man, combative when he felt he was misunderstood and, in this interview, determined to set the record straight about his motives and to make as strong a case as he could for the new approach to HIV/AIDS in light of the earthquake. Yet there were moments when his voice shifted from the calm avuncular tone of a physician to something more tender, more emotionally complex. This happened when he spoke of the horrors of life of the people living in the tent cities; it happened when he spoke of the Haitian people in general: "Our people are the best people in the world," he said, softly.
I had been told that we only had half an hour as Dr. Pape was extremely busy. He was generous enough, or simply engaged enough to give us more than an hour of his time. I left with a tremendous amount of respect for this man but also with a sense that whether intentionally or not, he was embarked on an ambitious process of expanding the work that he does, expanding an empire that, at its core, is focused on helping those who have suffered as a result of the earthquake—the 1.2 million Haitians displaced by the catastrophe.
Excerpts from Kwame Dawes interview Dr. Jean William Pape
HOW HAVE YOUR SERVICES BEEN AFFECTED BY THE EARTHQUAKE?
Normally we don't have an acute emergency hospital, but we had no choice but to transform our facilities, because people kept coming. I was here the next day after the earthquake and seeing so many people coming in with such terrible wounds. I have never seen such things as a physician. It was horrible. So we had no other choice. So now we have a rehab center. We had no choice—as Colin Powell said, "If you break it you own it." We didn't choose to do that. We didn't choose to do it, it was just something we had to do.
The reality is that after the earthquake we had to fulfill our traditional mission, which was to care for a huge number of patients with HIV/AIDS and Tuberculosis. We provide antiretroviral therapy treatment to 52 percent of all AIDS patients in Haiti. This is provided at 22 sites nation wide. Our first priority was to make sure they were safe and taking their medicine. So this was the number-one priority. Fortunately we had been through hurricanes and political turmoil so we have contingency plans in place and we are ready to deal with that. So this was not an issue, and within the first 10 days, we could account for 94 percent of the patients. We knew that 211 of them were dead. When the earthquake occurred I told my wife we were going to lose a lot of patients. Fortunately, we had relatively few of them die. People do realize that 15 percent of the population of the capital died, and another 15 percent of people were severely wounded. And of those who died 27 percent were public servants. So to have lost so few patients is a blessing. Because we were concerned that being poor they would be in tract houses that would not survive the earthquake but for some reason—I have my own theories—we didn't have as many of our patients die, which we are very happy for. Well, my theory is that in a way it is their poverty which saved them. Because they cannot afford to live in cement houses, that have cement ceilings and if you noticed around here 80 percent of the construction has been destroyed; we are really talking about constructions within 2 and 3 stories and mostly those with cement roofs. If you look at this place [GHESKIO's offices], this place was built about 15 years ago; there is not a single crack. The soil here is the worst that you can have. As soon as you start digging, then you can find water. And it was not built with earthquakes in mind, in terms of how to resist earthquakes. The roof is very light— a tin roof, and I think that that's how our patients made it. Also they usually live in a single room, unfortunately everybody in a single room, so they were able to alert each other that something wrong was happening and they got out. In addition we are providing care right here to a large segment of the population of two major slums: City of God and City of Eternity—right across here. It's a total population of about 300,000 people. Ironically, they got protected by the reefs. Because those slums, I saw them being built right in front of my eyes. They are built essentially on debris, which should make them vulnerable, but the reefs protected this area. So in many ways, many of them had their houses destroyed but things could have been much worse. So I said we had that major mission of taking care of our patients and we had traditionally provided for two weeks of extra medicine; we do that intentionally, because the problems here, whether political or natural, rarely go beyond one week. So if we have two weeks of extra medicine, we will be okay. We activated also our contingency plans because we had different places where people could get their medicines if they cannot come here. Sometimes if there is a strike we can divert them to different areas of the city where they can go and get their medicine. So we were not extremely concerned. And those people had been able to stay on their medicine. In addition, since we work at 20 sites nationwide, when there was the massive exodus of patients to go to the countryside, we were able to tell our patients where to go to get their medicines. Because we were in all the major cities -- Jacmel, Cayes, Cap-Haitien—we have physicians working at all those sites. So what we were not prepared for was the dimension of this catastrophe. We had three major additional tasks that fell upon us. The very first one was to provide acute care. We were not equipped to do that, so I reached to the USHHS [US Human Health Services] and they provided a team. That team operated on thousands of patients. They responded and the 82nd Airborne was here as well to provide security for them, and they were wonderful, they did a tremendous job, but when they decided to go, it was quite fast.
ABOUT HOW QUICKLY DID THEY LEAVE?
In fact they informed me one week ahead of time. So I really had to be prepared to assemble a team to take over because earlier while we worked in the triage area they didn't want to have other physicians as part of their team, which I think was a mistake because it would have made the transition much easier. In any case they did a great job, but we had to pick up the pieces and set up a rehab center, which now cares for over one thousand patients. I was luck to find probably the best orthopedic surgeon and also physicians trained in rehabilitation medicine. So they've done a terrific job and since this is not my area of expertise I asked my Cornell colleagues to come and do an audit on what we are doing and they sent me a five-page report (they have been here three times), to indicate that the job is great.
WHERE IS THIS REHAB CENTER LOCATED?
It is right here. It is headed by Dr. Hans Larsen and Dr. Jessie Geannot. They are the ones who are in charge of it—wonderful people. But now I have this, which I had not budgeted for and what they have been doing as well is train other people in physical therapy because there is huge demand from particularly the Government Insurance Company hospital to train physical therapists for the countryside. Because what has happened is when someone is physically handicapped, we had no infrastructure for that. And suddenly you have all those people with major handicaps. Now it's impossible to go to any downtown street and not see somebody walking with crutches. So what the population has done is send their loved ones to the countryside where they can get help. So the government has asked us to train people for those hospitals, which we have done. We have trained about 24 and we continue to do so.
So that's one major thing that fell upon us. The second major thing that happened is the fact that our brand new hospital in Leogane for tuberculosis collapsed. Four patients died there and we were taking care of the dangerous form of tuberculosis called multiple-drug resistant tuberculosis. To give you an idea, the cost of regular TB is about $110 and the duration is six months and the majority of people, 98 percent, get cured, whether you are infected with HIV or not. With this new form of TB the treatment is two years and the cost is $22,000 per year. The medicines are not good, the drugs are very toxic. It's much more than treating somebody for HIV. So they have to be in separate rooms, which we had before. So now they are under separate tents, on the other side near the U.S. Embassy. What we had to do also is collect all TB patients in all hospitals, because the Sanitarium of Port-au-Prince also collapsed. So we had to get all their patients. We had to get the patients from the University Hospital, from the University of Miami Hospital, and we continued to provide services doing about over 200 smears per day to look for tuberculosis in those patients. Because the major problem we are going to have with tent cities, is tuberculosis. So the third thing that happened to us—so I told you the first one is the acute care and rehab, the second one is the TB hospital and TB diagnosis, and the third one is that when I arrived here the next day, I found a large number of people on our campus—they took refuge there. They had lost everything so they came to us for services and as all our walls had collapsed more and more were coming everyday. By March we had over 7,000 people including about 2,000 children under five. So we had to set up acute care for them. So we have now—and you could talk to Dr. Peck and her team; Mireille Peck is the head of community medicine here, and she has done a wonderful job with her team. So everyday, we go into the camp to care and inquire about people who have four signs and symptoms: Asking whether you had fever, whether you had cough, whether you had diarrhea, and whether you had skin lesions. Anyone who has any one of those is seen by the dedicated medical team--the dedicated medical team for the camp. What I had to do also is create a committee for security and sanitation. So that we did gradually. We immunized everybody—children and women in particular. We organized the camp, we have a community leader in the camp, a president, secretary, etc, males and females. We hired about 130 people who were in charge of sanitation and security. I was able to indicate to President Préval my concern because the soccer field where they took refuge got flooded every year, because the land is soft, and with the streets that is higher than our level, when it rains, the water stays. So I was very concerned that even with the best type of care, we would have problems with patients contracting infectious diseases. So he was able to give us temporarily some land that belongs to the state, in fact belongs to Electricity of Haiti. And I prepared that land for about two months. That land naturally is above sea level so I was able to drain it. We dumped about 100 truckloads of gravel, and we were able to organize the camp very differently than what we found here. In the camp, every tent has a number, we have different quarters, we know by our electronic data system that tells us who everyone is in every tent; how many men, women, adults, children, we have. We have ID cards with photos for each member resident in the camp, and also, we had to deal with a huge problem. When people first came here we had a number of gangs in the camp, including former prisoners who had escaped from the National Penitentiary. We work at the National Penitentiary providing care for people who have HIV, TB and other infectious diseases. But over 4,000 left the penitentiary and many of them took refuge in the camp. So that created a lot of insecurity for the residents. But by having the card with a picture ID, we were able to make many of them leave the camp because they didn't want to have a picture ID, and the police arrested over… almost 300 people from our camp. They were carrying huge guns (sawn-offs, Uzis etc.), and this is why I mentioned to the 82nd Airborne Command not to patrol at night because the last thing you would have wanted is to have somebody kill one of those soldiers. And those guys, they are part of gangs, you know, and that wouldn't have mattered much to them. But many of those kids could have been my sons, twenty-years old. I was very concerned for their safety. Fortunately nothing happened and they were able to leave with having acquired an experience in this area.
So now our next major project, and I think it deals with some of the issues you had asked me related to what do we do with some of the HIV people living in the camp. If you ask me, my concern goes beyond HIV right now. It goes to the subhuman conditions in which people live in tent cities. Although conditions are much, much better in our new location—I can say for sure people are no longer sitting in mud because we were able to change that, they all have a proper tent, the tents are not leaking, etc. I pray that we don't have a major hurricane, and I yet, I also have a reserve of just a few tents in case something happens. You know, what you learn in Haiti is to have a contingency for everything. When we are moving them from one camp to another, the gang leaders did not want to, because they realized that they would lose control, and they created a lot of problems for us, they threatened our staff, they pulled guns, they pulled knives, but we were able to do it. What's amazing is that it is our women staff who did it—well, you will meet Dr. Peck. You see, she only had four women working with her, and they did that amazing job!
But my biggest concern now—and I think it is the biggest challenge that this country faces—you have 1.2 million people living in tent cities. Relocation doesn't just mean habitat. It would be too simple. Because when you are in the best possible habitat and you don't have any food for your children, you don't have any jobs, you don't have schools, you don't have health care, how good is that? And when you are going to relocate them it has to be to a community that accepts them. Because many of those communities don't have enough for themselves, so you have to prepare an entire infrastructure. The center I belong to at Cornell, is called The Center for Global Health. And global health, if you want, is a new concept that emerged in the U.S. in the last ten years. Every major U.S. university—there are in fact twenty—(I am leaving next week to go to that meeting in Seattle; it's the conference on universities for Global Health.) It involves the entire well-being of a patient. It's not just traditional health care: you have a fever, you are sick, we treat that. It involves everything that makes life worth living. It involves proper habitat, it involves job creation, it involves schools, etc. etc...So since we have been doing many of those things—we have a good micro-credit program that has been quite successful for some time, we have a school, now I have a school for kids…
AND THIS ALL STARTED AFTER THE QUAKE?
Yes, I have a school now for 300 kids, primary and maternal school, and we will build on this campus one of the best schools for underprivileged kids. I have been very much involved with the curriculum. I took curriculums from the best schools in the country, which is a French Lycee, and I have two consultants, one is a professor I have known for a long time who gives lessons to my kids, I had him adapt it to our population. We are now in the process of preparing a bid for the construction. It will build on this campus and construction should start no later than November so that the next school year, we can enroll those children.
SO LET ME ASK YOU THIS, THOUGH. THIS IS A TREMENDOUS AMOUNT OF DEVELOPMENT. THE OBVIOUS QUESTION IS DOES THAT CHANGE DRAMATICALLY THE WORK YOU DO WITH HIV? BECAUSE WHAT YOU ARE SAYING IS THAT A MORE HOLISTIC APPROACH TENDS TO BE MORE EFFECTIVE. IS THAT THE DIRECTION THAT YOU ARE GOING?
Okay, I must tell you that for about 10 years, I have been dreaming to go across the streets in the slums to set up global services for people living there. But I realized as well that we could not do it alone and I have been trying to convince Kiskeya University to come with education and some of the partners. And then with the earthquake, I didn't have to go to them, they came to us. So, I felt that this is part of our mission, it is complicated, but it has to be done. And as I said my vision is to work with the government to create a model village with a package of services so that we can give hope to this population and indicate what is the minimum package necessary for relocation. And the idea is that we have never had so many institutions and NGOs from outside coming. This one interested in habitat, this one interested in potable water, etc. etc...
What we need to do is say this is the package you need in order to relocate the population. You need to do your groundwork to make sure that all those ingredients have to be in place before you can do that. Otherwise, if you read what has been done in other countries, when you don't provide the services you create bandits, because when people don't have enough for their family, they just go out and try to get it the best way they can. And it's usually with gangs. And I don't think this country needs that. Of course it's going to be tough particularly during an election year. But I see no other choice. We think that if we do it, it will lead the way, it will show it is possible and people could come and learn with us. In fact my challenge to those 22 North American universities is going to say, "Look, come, each of you. Pick a tent city. But do it right. Global health should not just be a concept. Put it to work. Test the concept. Our people are the best people in the world. You see you came here you did not see anybody with guns. We never had anybody with guns. I work very late, ten, eleven p.m. at night, I never have to worry about anything. No one here has ever been attacked. So these are the type of people we have. And I think our greatest strength in Haiti is our people. So this is why we need to do everything we can to provide as soon as possible a decent life for them, and all they need is a little push.
DO YOU ANTICIPATE THE TENT CITIES THEN BECOMING MORE PERMANENT COMMUNITIES? BECAUSE, OF COURSE, IF THEY REMAIN CAMPS THEN THE PSYCHOLOGY OF CAMPS, THE DISPLACMENT PSYCHOLOGY, WILL PERSIST, WHICH IS PART OF THE STRESS THAT PEOPLE UNDERGO. SO IN YOUR VISION, DO THESE BECOME PHYSICAL COMMUNITIES WITH BETTER INFRASTRUCTURE AND SO ON?
Well, essentially, this is the situation. And I think the government has addressed this relatively well. You had people coming from two locations. You had people coming from the south of Haiti and people coming from the north. Those who come from the south tend to stay in slums closest to the southern border of Port-au-Prince. The same for the northern border of Port-au-Prince. So what they have done, and I think this was courageous, was to identify land in the south and in the north where relocation will take place. Now they have…One of the first considerations they are looking at is there are people who have damaged homes. They will try to help them to rebuild, to renovate. This is going to be the least costly proposition. The second least costly proposition is to encourage families to give them some support to have perhaps other members of their family live with them if their home is fine. Then the third and the hardest is relocation. Now clearly you cannot relocate people into an environment that does not provide services. So those services don't exist right now. They have to be created. Otherwise you will put them there, and they will not stay there. Nobody would stay there.
So if you think of what would happen to you if you were in a place like that and they put you somewhere else how would you feel? So this is why I discussed with our tent-city relations, I have met the [tent-city] committee and discussed with them many times. I have said, "Look, we will not force you to go anywhere. This will be your choice. We want you involved in determining your own future. And you will take part in all discussions regarding the type of habitats, the type of structure, how we should rebuild, because it's your life that is concerned, so you have to be involved in all these decisions. But be wary if they want to relocate you without any of those services. Because they are essentials."
So we have had this kind of discussion with them. But as you know, it's going to be difficult. The Ministry of Health with whom we are working—we have a one-day workshop essentially on this—the Ministry of Health say that it is no longer GHESKIO's project, it's their project and we are very happy with that. We don't want to take any paternity over this, we just want to make it happen. And will provide all the support needed. It will not be the GHESKIO Village; it will be a model village where we will try to get as many partners as we can. We'll take help from all our traditional partners: Cornell University, Fondation Mérieux; every other institution that wants to work with us. We are very lucky to have Electricity of Haiti on board. Electricity of Haiti is the company next door. Fortunately you see that their building is intact. It was built to withstand earthquakes and it did. The director of the company is very much involved with us in all stages of the process. It is their land that is being occupied right now by our tent-city population and they will play a major role because electricity is key also in relocation. So I'd like to move this beyond HIV/AIDS, as I said. Because to me if you limit this to HIV/AIDS you are not doing justice to the entire population affected by the earthquake. If you go in the camps, perhaps three percent are HIV-infected; what do you do with the 97 percent who are not? Are you going to say I am going to help only those who are HIV-infected? What about those subject to contract tuberculosis? Some of them are HIV-infected but most of them aren't. So I'd like to look at this more broadly. And I think also by doing so, you remove any kind of stigmatization that could potentially occur against HIV/AIDS patients.
CAN YOU EXPLAIN THAT A LITTLE BIT MORE?
Well, it is very simple. You have 15 percent of people dead. 80 percent of structures destroyed. Another 20 percent of people wounded. 1.2 million people living in tent cities in horrible conditions. I think the priority, if you ask me, the priority is not just HIV/AIDS. The priority is how can we move in the best possible conditions to definite sites, 1.2 million people. Because by doing so, you will also help control HIV, and you will help control TB. So instead of looking at the problem from an HIV standpoint, I am looking at it from a justice standpoint, from a human rights standpoint. No one of us would like to be in a tent city, whether we are HIV-infected or not. So I don't want to see it as an infectious disease physician. I would like to see it as a human being, as a Haitian who does not want to see his brothers and sisters live in those conditions. So that's the way I am looking at it, and this is why sometimes people think that I am saying that we don't have an HIV problem. Those are the activists who focus only on HIV. The problem is beyond HIV/AIDS, the problem is that you have 1.2 million people who live in horrible conditions, and that includes people who live with HIV/AIDS and TB. But the majority don't have HIV/AIDS, but they may contract HIV and TB if we don't do anything for them. So we have to look at the program more broadly and look at the problem in terms of human rights, human justice. So that is my take on it.
AND OBVIOUSLY THERE HAS BEEN PUSH BACK. SOME OF THE COMMENTS I HAVE READ ARGUE THAT IF HIV IS ISOLATED IN TERMS OF THE PLANNING AND THE CARE FOR IT, IT WILL ULTIMATELY BE IGNORED BECAUSE OF THE STIGMA THAT SURROUNDS THE DISEASE. I THINK THAT THE ACTIVIST RATIONALE IS SAYING THAT WE HAVE TO KEEP MAKING ENOUGH NOISE, OTHERWISE THE TENDENCY IS TO IGNORE HIV/AIDS. HOW DO YOU RESPOND TO THAT KIND OF RATIONALE?
I don't think it is correct because the two major donors are PEPFAR and the Global Fund, and they are keeping their program active. We've had problems with the Global Fund in terms of releasing funding which makes it hard for us, but its more an administrative problem, it's not a vision problem that they are not interested in Haiti. So, to me, if your funding has not been decreased to any significant level (I believe it's decreased by 10 percent for the Global Fund and no decrease for PEPFAR); in fact USAID is involved in many other types of interventions in tent cities particularly aimed at preventing gender violence, so I like to make noise when it is needed, I don't like to make noise in a desert.
And I think that right now people will not take me seriously if I am making noise when the majority of the population which is not affected by HIV or TB is in this kind of situation. So I think that we should look at the problem more broadly and by doing so, I think it would be fair to everyone. I don't want to isolate HIV/AIDS and make it a separate issue. I would make noise about it if there is a definite intention to ignore the problem, but the problem is not being ignored. All the institutions—local institutions—dealing with HIV are still there. And in fact if I show you our data, we have been able to put many more patients on antiretroviral therapies since the earthquake.
I AM CURIOUS ABOUT THAT. WHAT IS THE ESTIMATE OF THE PERCENTAGE OF PEOPLE WHO ARE HIV POSITIVE WHO ARE ON ANTIRETROVIRAL DRUGS? I KNOW THAT SOME PEOPLE DON'T NEED TO BE ON ANTIRETROVIRAL DRUGS, BUT IN TERMS OF THOSE PEOPLE WHO ONE EXPECTS TO BE ON ANTIRETROVIRAL DRUGS AS AGAINST THOSE WHO ARE NOT ON THEM, WHAT IS THE PERCENTAGE?
Okay, I will answer simply and then I will give you also a more complicated answer. The simple answer is that everyone who needs antiretrovirals in Haiti can get it. Now who defines the needs? That is the question. Until recently we were using the WHO criteria of starting at 200 CD4 count which is different from what was used in the US and Europe where they start earlier: 350. We did a study that was just published in July in the New England Journal of Medicine comparing the two standards. So we took about 500 people in this group, one starting earlier, using US recommendations and European recommendations, and one starting using the old WHO recommendations. And the study obviously was blinded so we could not tell for sure what was happening but we had some clues that things were not going so well for those who started late. And we asked the DSMB (Data System Monitoring Board) to review the data. They did and they stopped the study. They stopped the study because it showed that there were five times more deaths in those who started late and two times more TB. So based on those recommendations the WHO changed the guidelines from 200 to 350. So based on this, I think that we should be putting many more people on treatment. I don't think we have exhausted drugs that are available and we should be able to recruit many more people who would not have qualified based on the old criteria. So if we use the old criteria, yes, everybody is covered, but if we use the new criteria, no. We estimate that it will involve putting about perhaps twenty thousand more people on treatment. Which is a lot.
WHAT ABOUT THE ASSESSMENT OF THE LIVING CONDITIONS, NUTRITION AND SO ON? SOME OF THE DOCTORS I HAVE SPOKEN TO HAVE SAID THAT WHILE PEOLE MEDICALLY SHOULD BE ON ANTIRETROVIRAL DRUGS, THEIR SOCIAL CONDITIONS, THEIR NUTRITIONAL CONDITIONS WOULD MAKE THEM RISKY PATIENTS FOR THAT MEDICATION, AND THEY HAVE SOMETIMES CHOSEN NOT TO PUT THOSE PATIENTS ON THAT MEDICATION.
Okay, we've done many evaluations. We do provide nutritional support here. We've been doing it for a very long time. We do it with an organization called Espoir Anaise. It is directed by Mrs. Gladis Lauture, and we have been doing that since 1991. Now, let me tell you something interesting. We have a nutrition unit here and we are going to have a nutrition center built right here. I am not building it on the other site—we have another site next to the U.S. Embassy—because the people who need nutritional support and evaluation are here. Before we do that, we are going to look at three sites—one in Peru, one in Jamaica and one in Mexico—essentially because I want to make sure that form and functions match. I want to build something and then to transform it.
We are lucky to get a $1 million dollar grant from the MAC AIDS Foundation, and I want to make sure it is used, really in the best possible way. So we know the people that need to get it. In fact we did a study using a product called Medicament Mamba. It is a product made with peanuts, it is made in Haiti, up in Cap-Haitien. We evaluated infants at six months of age because that's usually when the mother stops breast feeding, and we look at them—at stunting, at weight loss, and when we looked at all those parameters we were able to reverse that. So I think this is very hopeful for Haiti. Not only is it done in the country and it gives work, but also we are able to prevent severe malnutrition in many cases. Now what we need to do also is work on adults. You may be surprise that the food that is provided is often sold right here. We have somebody who comes and buy the food. We estimate that about 40 percent of people who get food from us sell the food. Now we are doing a study to find out what do they do with that money. Is it because the food is not palatable? Is it because they buy other food, or is it because they have other needs? So we are looking into that. So that is why, really, having a nutrition center is really essential. Now to answer your question, all of our patients on ARTs in need, do get food supplies. In fact, we want to include in our guidelines proper nutrition as medicine against AIDS, because many patients will not take their medicine if they don't eat. And I think it would be self-defeating to provide medicine without doing that because you risk having them develop resistance, and that will complicate the treatment. So to make a long story short, nutrition is an essential part of HIV care. Do we have enough food? No. I wish we had more.
DO YOU HAVE ANY SENSE OF WHERE THINGS ARE IN TERMS OF HIV SINCE THE EARTHQUAKE? THERE IS A LOT OF ANECDOTAL INFORMATION ABOUT THE HIGH POSSIBILITY OF GREATER CONTRACTION—THE HIGH LEVELS OF RAPE, STORIES ABOUT MORE SEXUAL ACTIVITY BECAUSE OF INACTIVITY, AND SO ON. HAS ANY EFFORT BEEN MADE YET TO START TO ASSESS THAT TO SEE WHERE THINGS ARE?
We have done all the national surveys to look at trends in HIV, syphilis and hepatitis. We've done them since 1993. We've done five. There has not been any evaluation since the earthquake, so I don't want to theorize that it's going to be higher or lower. If you ask me, are the conditions assembled to worsen the situation, I would say, probably yes. But at the same time they are also there, if you use them properly to improve the situation. Because you have a captive population. And you see, I would like to see, instead of looking at the bad things, to see how you can transform the bad things into something good. In our camp, we have regular sexual education. We provide condoms. And I think that if we are able to provide work (which is the most important one) and inform people… in fact what I would like to do is throw at this captive population everything we know that works against HIV/AIDS.
So it's all up to us. If we do our homework and we put our will together, there is every chance that we will reduce further the importance of HIV/AIDS. But if we sit there and cry and raise our arms and say that things are not happening, etc., etc., we need to plan, and what I would like to see is all of us together covering all the camps. Now you need to refocus the fight against HIV/AIDS. The capital of Port-au-Prince and the West Department General account normally for half of all cases in Haiti. They also account for half the cases of TB. So if we are able to focus our energy to those vulnerable populations that also offer the opportunity to provide services, I think that we would have made a lot of progress in the fight against AIDS. So bottom line is, is the situation worse? I don't know. Are we seeing more rape cases? Yes. In fact we are the first site that started providing complete services to rape victims. Are we seeing more cases now? Yes. In fact before the earthquake, Haiti was the most secure country of the entire region. The earthquake has changed that and we can understand because people have not realized they blame the government.
But imagine that you had this calamity in the US, where you have the president, all the ministries, congress, everything destroyed, your police, the UN forces (we tend to forget they lost 101 persons, and 500 were buried under the rubble. The head, Ms. [Heidi] Anabi, died. So what happened here is beyond anything that has ever occurred, so we have done relatively well considering that there has not been any epidemic in the camp. There could have been epidemics of TB, malaria, typhoid, infectious diarrhea—we have not seen any of that. Now could the camps be better served? Yes. I will never be satisfied until all the camps are removed and people are placed in what I call decent sites where they have a package of services. But in the mean time it's not going to occur overnight, so we need an interim plan that will focus on tent cities with the ultimate goal of a complete relocation in the best possible conditions.
THANK YOU SO MUCH. I COULD ASK SO MANY QUESTIONS BUT I KNOW THAT THE TIME IS TIGHT. THE LAST QUESTION IS TWOFOLD. ONE IS, YOU SEEM… I THINK THE BEST WAY TO DESCRIBE IT IS THAT YOU SEEM OPTIMISTIC, BUT IN A VERY PRAGMATIC WAY. WHAT ROLE DO YOU SEE THE SMALLER GRASSROOTS ORGANIZATIONS THAT DEAL WITH HIV/AIDS ISSUES PLAYING IN THE LARGER WORK AND HOW DO YOU SEE THEM FUNCTIONING?
I think essentially, we should enlarge our vision. And while making sure that AIDS patients are covered we should look at the broader picture. The broader picture is that you have over 1 million people who live in the worst possible conditions. My analogy is that if you have 7,000 people who are hungry are you going to say I am only going to focus on those who have HIV/AIDS? We have a human disaster. It is beyond HIV/AIDS. It's a disaster that questions the essence of life, and to me there is nothing more important than that. I don't want to reduce it to a particular disease. I have fought my whole life and I continue to fight against HIV/AIDS, but now I am fighting for life, for justice, for decency, and to me I refuse to reduce it only to the level of HIV/AIDS. It would not be doing justice even to people with HIV/AIDS because if we do, they will get services in tent cities, but they will never be relocated like that. So we want to look at the broader picture, the picture that indicates that you have a major human dilemma. You can't reduce it to the dimension of any particular disease. It's a situation that deals with the essence of life.
THIS IS NOT A COMPLETE CHANGE FOR YOU, BECAUSE YOU WERE THINKING OF STRATEGIES IN THE PAST, BUT IT SEEMS LIKE YOU ARE MAKING A FAIRLY STRONG SHIFT IN EMPHASIS. IS THAT FAIR OR IS THAT OVERSTATING IT?
It's fair only to contrast with those who want to keep HIV in focus. I remain committed to fight HIV/AIDS, to fight TB and Human Papillomavirus, and all the disease that are afflicting our population—but at the same time I have to see that we are something broader than that. And I did not want the earthquake but it fell upon me. So am I going to say that I am going to save only those who have HIV/AIDS? I think that would be wrong and that would be creating stigma and discrimination against those who don't have HIV/AIDS, to the point that people would want to acquire HIV/AIDS in some ways. But you can see that this is silly.
Video for this post shot by Andre Lambertson and edited by Jake Naughton.