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We came to the orphanage in Fondwa early one evening. Dozens of tiny shirts hung on clotheslines near two dusty cinder-block houses. The compound looked deserted until a little boy popped into view, shrieking with joy, and a swarm of bouncing children materialized around us. Little hands tugged at the hem of my shirt, and boys and girls raised their arms and pleaded: “Lift me!” As I raised one sniffling girl from the crowd, she heaved a giant sigh and buried her face in my neck. I recognized some of the youngest children from the clinic that morning. We’d treated them for ringworm.
The several hundred orphanages in Haiti take in only a tiny fraction of the country’s 421,000 parentless children. In Haiti, women are roughly two hundred times more likely to die during childbirth than women in the United States. Only a short flight from the glitzy resorts of Florida’s coast, Haiti is a different world — a world mired in a history of political strife and with almost no awareness of public health. In Florida, the biggest killer of children under five is drowning; in Port-au-Prince, a leading killer is diarrhea.
Traveling to Fondwa was like flipping through the pages of a travel magazine. My companions and I bounced along dirt roads in the back seat
of a converted dump truck; the cliff face stared us down from one side. On the other side, the mountains dropped away to steep hillsides and then to the valley stretching to the sea. At the side of the road, women with huge woven baskets resting atop their heads exchanged greetings. I was traveling with a delegation from Family Health Ministries, a Triangle-based nonprofit that assists needy families in North Carolina, Tanzania, Guatemala, and Haiti.
When we reached the clinic in the mountains of the rural south, we set up two benches inside the first room for triage; stocked the shelves of the next room with ampicillin, cotrimoxazole, Tylenol, and two dozen other medications; and threw a few boxes of latex gloves and alcohol pads in the two adjoining examination closets. We were open for business. I set out the blood-pressure machine and our portable scale, and peered from the doorway of the triage room onto the porch, where a line of thirty men, women, and children already sat waiting patiently. I settled at a small table just inside the clinic’s door and fell quickly into a routine of taking vitals and chatting.
I had come to Haiti because I wanted to see, firsthand, how politics affect the way communities cope with sickness and health. In this place where the United States has had a century of close involvement, whole populations live and die almost without notice.
Everybody who goes to Haiti must fly into Port-au-Prince, the capital. As soon as I arrived, everyone warned me to stay in the guest house in one of the city’s wealthy enclaves. Anywhere else would be unsafe, they told me, and so we were confined to the hilltops overlooking the poor areas of Port-au-Prince. But I was determined to see the country beyond this insulated world.
Locals say the social strata in Port-au-Prince correlate with elevation: If you can afford a house on the top of the dusty, deforested hills, you can choose to remove yourself from the surrounding hardship. But if you’re one of the millions who live down below, in shanties, you worry about subsisting, and you follow politics because they affect your survival.
In 2004, the year Haiti celebrated the two hundredth anniversary of its independence from France, the country has suffered a political coup, devastating hurricanes, violence, and worsening health conditions. Social services don’t exist for the poor, who are getting poorer, or for the sick, who are getting sicker. Those who live there say that conditions are worse than they have been in decades.
Getting around in Port-au-Prince was more difficult than I’d expected. Public transportation was out, as shootings downtown had scared away the tap-taps — brightly decorated pick-ups converted into taxis. Fortunately, the manager of the guest house gave me a ride to the General Hospital, where I met Anne Sosin, a human-rights monitor for the Institute for Justice and Democracy in Haiti.
Late in the day, as Anne and I stood outside the hospital’s main doorway, a woman mopped dark stains from the floor. She bent at the waist, and her hands guided a rag across the tiles. Anne told me that, almost every day, the walls of this waiting room are lined with gunshot victims and young, nursing mothers. Patients pay five Haitian dollars (about seventy cents) to enter, more fees to see a doctor, and more still if and when they need medicine or supplies. The morgue is chronically overcrowded.
Despite the often prohibitive cost of care and the frequent shootings downtown, the poor make their way to the hospital from slums all over Port-au-Prince. Anne’s job is to meet with victims of crime and record their testimony, each day documenting cases of human-rights abuses. She works mainly in Cite Soleil, a neighborhood just across town, where the one public hospital that served the neighborhood’s four hundred thousand inhabitants has been nearly defunct since August 2004. The residents have withstood full-scale conflict since September 30, 2004, when police opened fire on demonstrators whom locals say were unarmed. Surrounded on three sides by water, Cite Soleil is like a labyrinth with no safe exit. The main entrance roads have been gutted, and armed men wander along the slum’s borders.
Cite Soleil and other neighborhoods like it throughout Port-au-Prince are migrant centers. Slums that emerged first under the Duvalier regimes now brim with people who have moved there in an attempt to escape the periodic storms, floods, and other natural catastrophes that strain Haiti’s already fragile ecological system. When a few more centimeters of soil slide down the hill, crops yield too little to keep families fed and kids in school.
Options exhausted, these families move into slums in the city, where housing is so cramped that people sleep in shifts. Despite conditions that might smother hope, the urban poor create their own churches, schools, and, sometimes, clinics and orphanages. It takes ingenuity to survive. With few job opportunities, most people join the bustling informal sector; two-thirds of Haiti’s population is underemployed, according to the CIA’s The World Factbook 2004. To earn money, people hawk sodas and water bags or clean latrines at night — anything to sustain their families.
Returning to the guest house after visiting the hospital, I looked up a few staff members at the Centre Gheskio, an urban counterpart to Paul Farmer’s Zanmi Lasante, or Partners in Health, a pioneering service organization. Founded in 1982, Gheskio is the oldest AIDS treatment and research center in the world. Roughly 160,000 patients pass through its doors each year, almost all of whom receive free testing for HIV, syphilis, and tuberculosis, said Bill Pape, founder of Gheskio. He explained that Gheskio, thanks in part to a hefty Global Fund grant issued in 2002, works with Haiti’s Ministry of Public Health and Population, Partners in Health, and other hospitals to provide drug therapy to more than 1,500 of the roughly 60,000 Haitians who have full-blown AIDS.
Though the clinic is in one of the most dangerous parts of town, the threat of violence is not the biggest obstacle to care. Clinicians at Gheskio say a greater barrier is a lack of basic necessities. Strict antiretroviral drug regimens often require that patients take their pills with food and water. But Haiti is the poorest country in the Western hemisphere; 80 percent of its people live below the poverty line, and only 46 percent have access to potable water. Gheskio gives everyone who comes in the door fifty gourdes — a few pennies — for the bus, but the staff can grant food provisions to only a select few. And patients sometimes opt to use their supplemental meals to feed other hungry mouths.
Russell Horowitz, a researcher at the clinic, told me a story of a mother of six who can’t get to the clinic every morning and night to take her medication. “But if we send the food subsidies home, it’ll be distributed between eight or ten people, and she’ll still be vomiting up meds,” Horowitz said. “It’s a tough situation.”
The nation’s health crisis is not limited to the AIDS epidemic. Across the country, Haitian and visiting physicians and professionals have taken flight. Outside Port-au-Prince, quiet areas such as Fondwa haven’t seen violence for decades, yet they are paying the toll of unrest. There’s no truckload of foodstuffs to replenish dwindling supplies, and trips to restock the pharmacies have been postponed indefinitely as violence in the capital mounts.
If you live in Fondwa and want to see a doctor, you have to journey by car as much as an hour south to Jacmel or north to the Hospital St. Croix in Leogane — both options are expensive and time consuming. At the clinic where I worked, many of the people waiting in line had walked for miles from their small farms to get there.
One by one, patiently sidling up to our table, they pointed to their aching muscles and swollen joints and described to the translator and to me where their pain was worse. Young women handed sleeping, feverish infants across the table to me. We saw cases of malaria and eye infections, sexually transmitted diseases, and acid indigestion. A troop of children from the orphanage arrived at the clinic about midmorning, most of them with worms and scabies, fevers, and runny noses. Over the next three days, nearly 270 people filtered through the four rooms of our makeshift hospital. We quit when the shelves of the pharmacy became bare.
But drugs aren’t the only pressing need. Kathy Walmer, who has led delegations to Haiti for years through Family Health Ministries, explained that “Everyone wants to donate money for drugs, but it’s much more difficult to find money to build wells or preschools, or to help finance adequate nutrition or clean-water initiatives.
“Without good food and clean water,” she said, “drugs can only do so much.”
Since my return to North Carolina, I’ve struggled to translate my experience for friends and family who want to hear the stories. I scour the news every day for information about the Haiti I saw, but I’m skeptical about what I read in the press. Articles rarely mention the poor water quality or the dangerously low vaccination rates. They tend not to question the legitimacy of the interim government, or explain how the embargo of U.S. humanitarian aid blocks hundreds of thousands of dollars in loans that could improve public services.
Haiti urgently needs aid, but the complete answer doesn’t lie in duffel bags of medicine or transient day clinics. It depends on the recognition that the basic conditions for health are a human right, and a knowledge that alleviating the burden of disease has to begin with addressing the social and economic inequalities that tyrannize and oppress people.
When I arrived in Haiti, it seemed a world away from the comforts of my home. But after a few days in the clinic, I wasn’t sure I’d really gone so far. Aches and pains require care whether you’re in Chapel Hill or in Fondwa.
At the clinic one day, to the amusement of patients waiting outside, I tried to take a wailing toddler’s temperature. The child, maybe two years old, showed signs of infection — glassy eyes and a fiery brow. But he wanted nothing to do with my thermometer. As I tried desperately to explain that the process wouldn’t hurt him, he screamed, squeezing one ear then the other to his shoulder. One by one, the waiting men and women crept over to join me. Within minutes, I stood shoulder-to-shoulder with half a dozen patients, crouched in a semicircle, each of us clapping our hands and contorting our faces, trying anything to distract the hysterical child.
I was ready to give up when his older sister squeezed through the crowd. As I held her brother, she stood beside us, reached out, and pinched his toes hard. Finally, he forgot to protect his ears from my thermometer. 
