Medicine and Social Justice: A Summer in Haiti
by David Walton

Harvard Medical School's pre-clinical curriculum has some telling blind spots. During the last two years, we have spent a great deal of class time talking about coronary artery disease, a leading cause of adult deaths in the United States; in contrast, we devoted only four hours to the study of tuberculosis, the leading infectious cause of adult mortality worldwide. Entire lectures are devoted to the molecular permutations of glucose metabolism, while discussions of typhoid and cholera are deferred to "independent study." While the U.S. makes up only 0.045 percent of the world's population, our pre-clinical education is so designed that many of the most significant causes of global morbidity and mortality are neglected.

When they finally do address the topic of infectious disease, professors pepper their lectures with dismissive comments such as, "You don't have to worry about this because it is exceedingly rare in the United States," or, "This is not seen in the U.S." They fail to mention that many of the rare disease of the United States are significant causes of morbidity and mortality around the globe. For example, recent surveys suggest that some two billion people -- nearly one-third of the world's population -- are infected with the tubercle bacillus. Moreover, complications of HIV infection have become the leading cause of young adult death in cities throughout the Southern Hemisphere. Even in the United States, treatable infections continue to kill the poor. In a cohort of New York City welfare recipients, TB and HIV were the leading causes of death.

Between my first and second years of medical school, I was fortunate enough to spend a couple of months at the hospital in Cange, on Haiti's Central Plateau, run by PIH's sister organization Zanmi Lasante. My experience there was unlike any of my previous experiences abroad. The abject poverty and despair I witnessed is unparalleled in the western hemisphere. Haiti humbled me, brought tears to my eyes, and lit a fire in my heart.


Haiti

The further you get from Cange, the worse the living conditions become. Most of the peasants lived in poorly constructed shacks, and the condition of the houses was rivaled only by that of the land. I couldn't believe my eyes when I saw a woman planting seeds in what appeared to be a field of large white rocks. Then I noticed corn growing in the small spaces between the rocks. The hot, arid environment of the deforested Central Plateau acts like a kiln, scorching the earth, making farming virtually impossible. And yet that is precisely what this woman and her neighbors have to do in order to survive.

One afternoon, Paul Farmer and I stopped to see Adeline Mercon, a young woman suffering from advanced HIV disease. Most people in the United States would long since have been receiving treatment with state-of-the-art antiretroviral medications, coupled with antibiotic prophylaxis. But the annual cost of these medications can exceed $14,000, and initially PIH could treat Adeline only for her opportunistic infections. These came in rapid succession. In 1999, she was hit hard by a chronic enteropathy (an intestinal disease that causes a wasting illness). Her weight dropped significantly, and by June, when we saw her, she weighed 79 pounds and was too weak to walk.

That November, Adeline began therapy with three potent antiviral drugs to treat her HIV-disease. By January, she felt "better that I have in years." Adeline does not pay for her medicine, the cost of which was donated by the friends and supporters of Partners In Health. In addition to medication, she receives financial assistance and nutritional supplementation. Although many public-health experts would argue that it is not cost-effective to treat Haitian peasants with this type of chemotherapy, "unorthodox" solutions are necessary for a virus that makes its own preferential option for the poor.

Absoly was physically slight; his thin, sinuous build and work-worm hands revealed a lifetime of hunger and hard labor. Fifteen years ago, before the hospital in Cange was constructed, he fell victim to a serious infection in his right leg. Since Absoly had no money, he was unable tos eek medical attention. The infection progressed unchecked until it damaged the blood supply to his leg. The residual, necrotic tissue created an ideal environment for parasites, and his leg soon became infested with maggots. With the help of his family, he was eventually able to reach the nearest hospital, some six hours by foot. His right leg was amputated at the hip. After a long recovery, he was forced to use his hands to ambulate, as his remaining leg was misshapen and atrophied.

When we visited Absoly, he was living in a "house" with his wife and child. I use quotation marks because the dwelling was no larger than seven by five by eight feet -- there was scarcely enough room for his sleeping mat. The condition of the walls and roof were much worse than the other houses in the area, and provided little protection from the elements. As storm clouds were gathering, I stared at the dirt floor and at the thatched roof, imagining what it would be like to sleep there even for a night.

But just before our arrival, one of the Zanmi Lasante community-health workers had met Absoly in the course of a regular walk through the catchment area to identify people with acute social, economic, and health problems. Absoly had been chosen to receive a new house with financial assistance from Zanmi Lasante. As we spoke, less than 40 feet from his shack, construction workers were clearing the ground for a new home, which would be covered by a tin roof and have a cement floor.

Five weeks later, I paid my final visit to Kay Epin. Absoly's new house was almost complete -- the tin roof was up, the wooden walls were standing tall, and plans were underway to fill in the dirt floor with cement. As we were leaving the construction site, a community-health worker, reflecting on the role of PIH in rural Haiti, commented, "God catches the crabs and places them in the blind man's sack."


Hard Questions

During the course of my time in Haiti, I somehow began to lose sight of my own needs and desires. I began to care about other people more than I cared for myself. I knew, of course, that medical students are supposed to do this as they become doctors. But spending eight weeks in Haiti brought new meaning to this concept: I came to realize that the poor deserve preferential treatment. Diseases settle on the poor because they have been forced to endure hunger, famine, political violence, and social inequality. The Haitian peasants bear the weight of the country on their shoulders, and those who reap the benefits of their work -- from local landowners to transnational corporations -- use their power to exploit them further.

When I first arrived in Cange, I was so struck by the abject poverty and suffering that I wrote my friend of 15 years an emotional, heartfelt email. His response, which consisted of one line, shocked me: "Sounds pretty depressing. What else is going on down there?" I was not disappointed because I knew he and I were drifting apart. Rather, I was disappointed because he embodies the sentiments of the majority of people who have not know hunger, violence, and a near-total lack of health care. Their thoughts, much like his, are centered on themselves and their daily struggle. How will I advance my career? What new car will I buy? What is the latest fad on which I can spend hundred of dollars? Few stop to think about social and economic inequalities that surround them. But since he and I live in the same world as Adeline and Absoly, it takes effort to ignore them. As the liberation theologian Juan Segundo put it: "The world that is so comfortable for us is the same one that is so unbearable for billions of others."

I struggle to understand the apparent indifference of those, like me, who live in comfort. Sometimes, I wonder if we see the poor as another species. How can we invest so much passion in fighting for, say, the rights of animals when countless people die of curable infections? A recent document from the World Health Organization suggested that the amount of money spend on pet care products in the United States would be enough to eradicate TB, in addition to many other preventable diseases in the world.

But are the people of the United States really so opposed to a more just distribution of resources? Shodener Andre, a young Haitian boy from the Central Plateau who was diagnosed at the Clinique Bon Sauveur in Cange, recently received a heart valve replacement in Boston. From the moment of his arrival he was met by a score of people who were willing to help him. Complete strangers, gave him money, clothes, and toys. I believe that most people are sympathetic to those who are suffering or who face difficult challenges. Not too long ago a woman in the U.S. gave birth to septuplets. It was the buzz of the nation for a few weeks, and resulted in a shower of gifts, money, and material goods for the proud parents. They were even given a house! If people are willing to give so much for a middle-class couple with seven babies, how much might they be willing to give to the poor?


Pragmatic Solidarity

In July, Paul and I traveled to the southern city of Jeremie to attend the Haitian National Tuberculosis Program conference. On the first day, data were presented on cure rates for each Department in the nation. The Department du Centre, which includes the Zanmi Lasante catchment area, had the highest cure rate in the country -- over 90 percent of all TB patients registered could be considered cured. Another department, by contrast, had a 26 percent cure rate. The cure rates in the Central Plateau exceed some of those in the United States, and far surpass many other TB programs around the world. Everyone in the meeting was astounded. "How do you get such high cure rates?" asked the Surgeon General. Paul explained that, contrary to the belief of some in the room, patients are not inherently non-compliant (non-compliance is often cited as the reason for low cure rates, obscuring other factors that affect efficacy of treatment). Paul continued, "We have such high cure rates because we remove the barriers that prevent patients from complying." Cure rates in the Central Plateau were not significantly improved until Zanmi Lasante started giving nutritional and financial assistance to their patients. Free medications alone were insufficient. As the Haitian saying goes, "Taking medicines without food is like washing your hands and drying them in dirt."

The role of the community-health workers is also crucial to the success of the program. The 70 community-health workers are aware of their role in TB outcomes, and they aim to have zero patients abandon treatment this year. To date, no abandons have been documented.

While in Haiti, I was able to witness the final stages of construction of the new Thomas J. White Center. Imagine, a top-notch infectious disease center in rural Haiti! Surrounded by nay Sayers, PIH and Zanmi Lasante are building a facility to help people like Adeline and Absoly. In Creole, TB used to be known as "the little house of sickness," because those with TB were often sent away to live in small shacks. But the Center sits atop the tallest hill in the area: Dr. Jerome, medical co-director of the clinic, remarked to Paul that TB should now be called, " the castle sickness." The significance of this new facility is felt by everyone. Inpatient capacity has doubled, and the new lab is as efficient and reliable as any in the first world. Another radiology suite is under construction, and the new pharmacy is already stocked with medicines to treat TB, HIV, and STDs.

The 60 days I spend in Haiti were the most important of my life. I melted when I saw a mother and father smile with joy when their child was cured. I got goose bumps when I saw a patient with typhoid, who was bedridden a few days earlier, up and walking. I feel blessed to be able to work for PIH and to have become involved in such important work. As Jim Kim often says, there is not a long line of people waiting to fight for the social and economic rights of the shafted. I have already signed up for this battle. With the help of PIH, I am working my ways towards the front line.