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Some come here and die very rapidly.
A cool breeze is blowing as the wasted body of Jean David Droitdieu, carried down steep rocky trails on the shoulders of men chanting an almost cheery dirge, approaches his mother's house.
There's a faint smell of rum in the air -- it's what's fueled the men for this grueling journey, four hours' hike from the nearest road in southeastern Haiti. The men cross a shallow stream at the base of a deep valley, then lumber up a bank into a remote village of white stone homes known as Galette Mousambe.
The chanting ends, replaced by a long, pitiful shriek as the mother sees the corpse of her eldest son. Soon, dozens of friends and family join in a single violent wail that seems to fill the entire valley.
The mother's small house is quickly cleared of its furnishings and swept clean. The white-shrouded remains of the 28-year-old native son, the face soaked with more rum to mask the smell of death, are placed inside.
As one mother's lost son, the dead father of an orphaned child, a wise brother and good friend, Jean David will be celebrated for a night, then quickly buried.
As one more life claimed by AIDS, his death will be something less than a statistic. It joins countless other deaths, officially unrecorded, but mounting on a scale at which experts can only guess as the epidemic sweeps through the Caribbean.
"This was a good man, a very respectful guy," says Junior Droitdieu, the dead man's brother, as villagers try to console his mother. She rocks back and forth on her feet, wracked by heaving sobs.
"He worked hard, took care of his family," Junior says. "But now everything's gone -- I've spent all my money trying to buy him medicine, make him feel better. And now he's dead. But you know, I had to do it. I had to. He was my brother."
Now entering its third decade under the brunt of the epidemic, Haiti is the epicenter in the Caribbean's struggle with AIDS. This desperately poor nation has the largest number of cases in a region with one of the world's highest infection rates.
During the last two decades, an estimated 300,000 Haitians have died of the disease. It's by far the largest toll in either the Caribbean or Latin America.
All told, an estimated 87 percent of all AIDS cases in the Caribbean are occurring on Hispaniola -- the island home of Haiti and the Dominican Republic.
In both countries the disease is exploiting the same endemic poverty that has allowed it to wipe out a whole generation of Africans. And it moves effortlessly in a global age of international travel, tourism and weakened borders. Political upheaval, economic collapse and cultural taboos have allowed the disease to spread virtually unchecked.
"The biggest problem is medical care -- there really isn't any public medical care," says Jean Saurel Baujour, a leading AIDS activist in Haiti. "There is no national reference center. Not even the most basic statistics are really being kept.
"It's a long fight. It's a lonely fight. Many of us are going to die," concedes Baujour, who has HIV, the virus that causes AIDS. "We know that. But we can help change things for the sons and daughters that follow us."
By the time of Jean David Droitdieu's death on Feb. 28 at a missionary hospital near the Port-au-Prince slum called Cité Soleil, his brother had sold their small house and three cows to pay for medicine to keep him alive. The dying man's wife had abandoned him months before, returning only once to leave their infected daughter with Droitdieu's mother.
"Now the child is sick, too, but we don't know what to do -- she's only 14 months old," Junior says. "There's no energy and the baby cries all the time. We've already carried her to the hospital twice."
Galette Mousambe, where Jean David grew up, is a remote area without electricity, public sanitation or piped water. But it's hardly out of touch. Local youth, wearing baggy trousers and Chicago Bulls jerseys, tend goats and cattle along the rugged mountain trails while listening to hip-hop on Sony Walkmans.
Like many other Haitians in their teens, Jean David left for the big city at 15 to search for work. Two-thirds of Haiti's population lives in rural areas, but life in Haiti is one of constant movement between the city and country. In the last two decades especially, the major cities have swelled in population as more sons and daughters have left the severely deforested, eroded countryside looking for jobs as maids, drivers and street vendors. This movement has further fueled the spread of AIDS around the island.
Living with his younger brother, a laborer, Jean David found work as a driver of a tap-tap, the colorful buses built onto the backs of pickup trucks to ferry people around Haiti. He and Junior scrimped and saved, and eventually bought a house in Cité Soleil.
"The boy [Jean David] was healthy when he left here, a good worker, very vigorous," says his uncle, Jean-Louis Meyal. "He was working hard in the city and he would send money back to his mother."
Then, almost two years ago, Jean David came down with something resembling the flu. He rapidly lost weight, vomiting and spitting blood for days at a time, his relatives say. After visiting a series of doctors, he wound up in a public hospital, where patients can stay only as long as they can afford their medicine.
"I sold off the house one room at a time to pay all of this," Junior says. "I rented the rear room to a family to get some money, then I sold them a room.
Then I sold another room. I was living in the third room, but finally I sold that, too." The entire house eventually netted him about $700 -- almost twice the annual salary for the average Haitian.
Doctors, who in poor areas charge about $1 for office visits, are ill-equipped to deal with sickness as debilitating as AIDS. Though many doctors advertise the availability of AIDS tests, they usually don't give them until a patient is showing symptoms of full-blown AIDS, health workers say. When they do test, the doctors often don't even tell their patients they have tested positive.
"What we find out is when we tell the patient, they tend to die sooner," says Dr. Michel Thomas, a doctor who has a small practice in Cité Soleil. "They just lose hope. The stigma is so great here against AIDS, you just tell them they have TB or another opportunistic infection.
"There's simply no medicine I can give these people in most cases," Thomas says. "Even if it just was TB, the treatment for that is expensive, beyond their means.
But AIDS -- so many times the patient wants to just disappear, to quarantine themselves from families. So they find a room somewhere and waste away."
In a narrow, cramped examining room littered with hypodermic needles, Thomas says he averages at least one patient a day who tests positive for the virus. Last year he diagnosed 350 people with the disease. During the first two months of this year, he saw more than 70 new patients who are HIV-positive.
On this day he is examining a local schoolteacher. The man, gaunt and exhausted, sits hunched over on a rusting examination table in an unlit 6-by-6-foot room. He tested positive in October after becoming so weak from weight loss and frequent diarrhea that he no longer could stand in front of his elementary school class. But instead of telling his patient that he had the AIDS virus, Thomas called the man's minister. The minister informed the patient's wife. All agreed that telling the teacher would probably end up killing him sooner.
"This is like a special case -- he is a church member," Thomas explains. "It was a decision we made in part because it would have created a scandal at the church. They would have hounded him out of the community."
It was this fear of becoming outcasts that influenced Junior's choices as he carried his brother from doctor to doctor. Usually he selected doctors well away from his neighborhood. Finally, unable to pay any more, Junior brought Jean David to the Sisters of Charity clinic in Cité Soleil.
Jean David took a metal bed with a number painted on it in a room with eight other patients. The hospital usually has about 40 male patients. Women are treated at another hospital that is more isolated from the public because of the greater stigma attached to females who test positive. In Haiti and other Caribbean countries, a woman who is HIV-positive risks being labeled a prostitute by her husband. The assumption is that her husband would not infect her, so she must be unfaithful.
"Some come here and die very rapidly. Others, we can treat for the TB, the diarrhea, and they'll leave for a few weeks, maybe even a month or two," says Brother Henry Kullu, a missionary in charge of medicine at the clinic, which is part of the order started by the late Mother Teresa of India.
"But then they come back again, then again," Kullu says. "Each time is shorter, then they finally come back for the final time. Most, even if we don't tell them, know what they're dying of. They know it in their hearts and the struggle then is to accept it, and start planning for their wives and children."
Just after dusk, it becomes clear that Jean David is in his final hours. His arms are so shriveled that the doctor can no longer find a vein to give him liquids intravenously. Relatives begin arriving from the countryside, and the missionaries search for a light bulb to hang above his bed so Jean David can see his family.
Lifted up from his pillow by his brother to sip some 7-Up, Jean David repeatedly asks to be taken to his mother's home at Galette Mousambe. For Junior, that poses a dilemma: If he leaves to scrounge up money for a tap-tap, he might miss his brother's death. But if he transports Jean David back to his village while he is still alive, it will be several dollars cheaper than moving a corpse.
"Basically, we've given up hope," Junior says. "It's hard to admit, but I'm sitting here waiting for him to die. And I don't have the money to move him, but he really wants to go home. It's just going to be cheaper if he's still alive when we get in the tap-tap."
But Jean David dies hours later, taking his last breath just before midnight. His body is wrapped in a sheet with his belongings and loaded onto a white truck that carries him to Bainet, where the road ends.
Outside Bainet, Junior quickly rounds up several of Jean David's friends who agree -- in exchange for a bottle of rum -- to carry the body to his mother's house on a stretcher made of freshly cut bamboo lashed together with vines. The men pour rum over Jean David's face before the journey begins, a sort of final toast to their departed friend.
The body is then wrapped in a mat and his face is covered. With that, they begin their trek up the mountain. A crowd of women and children has gathered around to see them off. After a few minutes they pick up speed, almost dancing as they begin a chant about Baron Samedi, the mythical gatekeeper who watches over the dead in Creole folklore.
Now that you're dead We're going to bring you To Baron Samedi So that you can be laid to rest!
In Haiti, officials with the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimate that early this year as many as 330,000 were infected with the AIDS virus -- 12 percent of the urban population and 5 percent of rural inhabitants.
But as large as its problem is, Haiti is not the only country seriously threatened by the epidemic. In the Bahamas, 4.1 percent of adults are infected with the virus. AIDS is now the major cause of death among young men between the ages of 15 and 44 in the English-speaking Caribbean. In some parts of the Spanish-speaking Dominican Republic, it has become the leading cause of death among women in the same age group.
More alarming, some experts say, is the increase of infection among expectant mothers. In Haiti and Guyana, 7 percent to 8 percent of expectant mothers are HIV-positive, a staggering rate that suggests the scale of contagion.
"A pregnant woman is a window on the world -- she is young, she is getting pregnant and will become a mother," says Dr. Peggy McEvoy, the former UNAIDS official. "It gives you a look at the general population, a group of people with normal expectations of life, and what's going on there.
"Once it crosses 2 percent of pregnant women -- that's a serious epidemic," McEvoy says. "It's now spreading throughout the general population. In [some areas of] the Dominican Republic, for example, you're seeing it grow from rates like 2 to 4 to 8 percent of pregnant women. That's incredible -- that's a wild epidemic."
All of this adds up to the early stages of "a major developmental catastrophe" that could reverse social and economic achievements of the last 50 years in the Caribbean, according to the World Bank. That would raise serious foreign policy issues for the United States, the destination of choice for refugees from the Caribbean. The region's tourist industry could easily collapse under the weight of the epidemic, leading to political and social disarray.
Because it can lurk for five to 10 years inside a person before any symptoms show, AIDS strikes hardest at poor countries whose citizens lack even basic access to health care. By the time a person is diagnosed, it is often because he has AIDS-related conditions such as tuberculosis, pneumonia and dementia. Many are too far gone to help. The disease spreads primarily through heterosexual activity, which means young men and women are most at risk. And they are the backbone of a developing economy.
One study by the University of the West Indies estimates an AIDS-linked decline of about 5 percent in the gross national products of Trinidad and Jamaica in five years. Already, an estimated five years has been shaved off the average life span in Haiti and Guyana -- down to 47 for men and 51 for women in Haiti, and to 57 for men and 62 for women in Guyana.
There is no AIDS vaccine. The drugs available in industrialized countries, anti-retrovirals that can contain symptoms, are coming down in price but still remain out of reach in countries where annual per capita incomes are as low as a few hundred dollars.
AIDS is basically treated as a death sentence in poor countries such as Haiti. Many physicians treat whatever symptoms they can, then send patients on with anti-bacterial medicine to treat opportunistic infections. The vast majority of the sick are on their own. Once symptoms develop, the ill lose jobs in manufacturing, services or agriculture. Their meager savings are quickly eroded in a desperate bid for medical care. Households collapse. Spouses often abandon their sick mates because of fear and stigma. Children are orphaned to the streets.
Some linger on, relying on money sent from relatives in the United States -- a key source of income for many countries -- to buy expensive drugs instead of paying for food, homes or school tuition for their children. But the cruel calculus of the disease is unrelenting.
As men die, their wives and female companions are left fending for themselves in societies that have few opportunities for women. Because of the sexual stigma attached to AIDS, few women come forward until they are showing symptoms. And by then, it's often too late.
As one parent dies, the family's income dwindles. Jobs are lost. Houses are often sold off, along with cars, livestock and other belongings, to pay for treatment. In poorer countries such as Haiti and the Dominican Republic, there is no such thing as insurance to supplement government health care.
With the death of the second parent, children are sent to live with relatives or shoved into the streets, where they become a criminal tax on society. In Haiti and Jamaica, roving bands of street children are common sights. Children left parentless by AIDS are filling orphanages and children's homes.
This process -- the slow, unremitting destruction of poor families by the disease -- is occurring every day in Haiti and the rest of the Caribbean.