COLUMN ONE : AIDS Fight Casualty of Haiti Coup : The regime halted testing, shut clinics and diverted medicine. The virus spread to the countryside. A nation unfairly branded when world epidemic began faces new problems.


As the celebrations of this nation’s new democracy swirled around the Croix des Bossales market where she had sold drinking water for years by the glass, Rita Jean-Gilles was too weak to stand, let alone march.

Her chest hurt. Her feet were swollen. She had survived years of crushing poverty, military oppression and an illness she still denies. But now she had no time for democracy, no strength to welcome the 20,000 American soldiers who had come to liberate her land from the nightmare that had so sapped her strength and her nation.

All that was left for her was to die.

So Jean-Gilles, 38, called for a boy she knew at the market. He helped her across town to Mother Teresa’s Sisters of Charity hospice and up to the second-floor women’s AIDS ward.


Jean-Gilles already had visited there three times before. But this time, she would join a record number of terminal patients, ages 14 to 58, in the overflowing ward. Together, they are symbols of what the Sisters of Charity and other experts on Haiti’s AIDS epidemic agree is among the worst, hidden legacies of the horror of three years of brutal, military-backed rule.

“It’s getting worse now,” Sister Harshid said of the increasing numbers of Haitians dying from the combined effects of acquired immune deficiency syndrome, deepening poverty and official neglect.

“All these young girls you can see--teen-agers and the older ones as well--they have been here three or four times,” the nun said. “On the third or fourth time, they will die here. Two or three die here each day now. There is nowhere else for them to go. It’s because of the poverty, and it’s because of the problem.”

That “problem,” as Sister Harshid calls it so politely, haunts Haiti, a nation that mistakenly became synonymous in most Americans’ minds with AIDS when the disease was identified and publicized in the early 1980s.

The fight against the spread of AIDS and any effort to help those infected with the virus are daunting tasks that outstrip the resources of local authorities and the mandate of the current U.S. military operation to restore democracy to Haiti.

Among the obstacles is more than a decade of stigmatization in a population with intense national pride, experts say.

When confronting AIDS, Haiti remains a nation in denial. It also is a country with an unusual set of heterosexual relationships that seem tailor-made for the spread of HIV, the virus that causes AIDS. But three years of dictatorship clearly compounded the problem.

In the havoc of military repression and the isolation of international sanctions, officials have lost track of how many have contracted HIV or died of AIDS and how fast it is spreading. Based on projections from 1991 data, the generally accepted figure in the AIDS community is that 10% of Haitians carry the human immunodeficiency virus. (In the United States, the infection rate is estimated at less than 1%.)

But AIDS experts interviewed in Port-au-Prince say one recent independent study proved the military regime’s greatest impact on the spread of the disease was geographic. For the first time, they say, the epidemic has spread to the countryside.

The Haitian army’s waves of terror were aimed at rooting out pro-democracy supporters in the cities, as well as the countryside, after the 1991 coup that overthrew President Jean-Bertrand Aristide. But the military inadvertently transformed an urban epidemic into a nationwide disease almost overnight: HIV-infected city dwellers fled to the relative safety of remote villages, where infection rates are now nearly equal to those in the cities for the first time since the disease was discovered in Haiti a decade and a half ago.

An official with the U.S. Agency for International Development--which spends about $2 million a year battling AIDS here--said the HIV infection rate in Port-au-Prince was estimated at 3% to 11% of the population four years ago, but was virtually zero in the countryside.

“After the coup and everything that has happened in the last three years, it’s a lot more than zero,” the official said. “Nobody really knows what it is, in fact, because no one has been able to keep an accurate track on the spread of the disease during these years.”

The town of Mirebalais, on the road between the capital and the isolated Central Plateau, is a dramatic example.

The town was virtually AIDS-free before the coup, according to a private AIDS research center founded by Cornell University that studied the population there. Now, of Mirebalais women ages 14 to 24 who gave birth in the past 20 months, at least 7% were HIV-positive; none knew they were infected.

In the cities, military rule also left a grim legacy. AIDS research and treatment were all but halted, health officials say. The regime’s puppet government suspended free HIV testing after an international embargo made it more difficult to import test kits. An AIDS hot line was diverted to the regime’s use.

The extensive network of Haitian religious and humanitarian groups that had been working to combat the disease at the grass roots quickly became targets of the regime, which suspected some might support the exiled Aristide and his pro-democracy struggle.

Doctors were jailed as suspected activists, clinics were shut down, and desperately needed medicines and spare parts for sophisticated medical machinery were diverted by the military or kept out under the trade embargo.

“People are poorer,” said Joan Atkinson, who has worked for four years as the American project officer for a Johns Hopkins AIDS and tuberculosis program in the Port-au-Prince slum of Cite Soleil. “There are fewer resources. The (support) networks were all disrupted. Gas was so expensive people couldn’t afford to get to the clinics and doctors couldn’t reach the people. People were afraid to go out. And few could afford medicine. Everything was just more desperate, and that goes for the fight against AIDS as well.”

As a result, scientists and researchers have all but lost track of the disease in Haiti.

“There hasn’t been a government here in so long no figures have been published,” said Bob Clark, who works for the only AIDS prevention program that thrived under the regime--an innovative, U.S.-subsidized marketing program for condoms that was launched in 1991.

“We’ve been lucky for three years partly because there hasn’t been a government and no one paid any attention to selling condoms,” said Clark, whose company’s condom sales in this predominantly Catholic country soared from 30,000 a month in 1992 to 350,000 the month before Aristide, a former Roman Catholic priest, returned.

The few statistics that are known about AIDS here are chilling.

Even if the virus’ prevalence remains stable, by 2010 there will be 60,000 AIDS babies in a nation already ranked as the poorest in the Western Hemisphere, said Clark, quoting estimates from the Cornell-funded research institute.

And beyond the statistics are the myths that continue to fuel Haiti’s AIDS stigma.

So great is the fear and misunderstanding of the disease in Haiti that U.S. Army doctors with the intervention force were told in Pentagon briefings that this nation’s infection rates are as high as 40%; all American medics treating Haitians have been ordered to wear double gloves, including a thick, black rubber pair usually used to handle toxic waste.

This AIDS stigma, which has attached itself for more than a decade now to this fiercely independent nation, deeply upsets Haitians who see the disease as an American phenomenon and, for some, an American conspiracy to taint Haiti’s image.

In an earlier time, a brochure advertised the now-abandoned Port-au-Prince resort called Habitation Leclerc: “Luxury in an exotic garden”; and “Eleven hidden pools and your destiny.” Color photographs promoted a 33-acre secluded estate where men and women struck intimate, half-naked poses.

The brochure was published in the 1970s, before AIDS was discovered. And AIDS researchers here now cite the exclusive resort as just one of many oases for sex tourism in Haiti--an industry that mainly drew thousands of vacationing American gays to Haiti’s pristine and secluded beaches.

AIDS experts now say that this most likely was the way that HIV made its way into this Caribbean nation.

“Haiti was a tourist resort for the neat, hip people of the ‘70s,” said an American aid official, citing resorts like Habitation Leclerc as sex magnets that “catered to gays from the U.S., particularly New York and Washington. You had a lot of Haitian men and boys driven by economics into working as homosexual prostitutes. They then returned to the girlfriends or wives, and the rest was history. I think it’s safe to say that the entire health community working with AIDS here is convinced the disease was brought here by Americans.”

The irony was twofold: When the virus was discovered in Haitians in America in the earliest phase of HIV testing, many scientists speculated that the disease originated in Haiti--a conclusion that still embitters most Haitians. That scientific speculation destroyed the valuable tourist industry almost overnight, helping to perpetuate the nation’s enduring poverty.

Referring to scientific perception at the time, which was later disproved, Atkinson observed: “It was the three Hs at first--homosexuals, heroin and Haitians--even before hemophiliacs were added to the list. It upset almost every Haitian, and continues to do so. The important thing now is to take away the blame and the stereotype. It’s just not like Africa--far from it.”

With the prevalence of HIV here at least four times lower than the world’s worst-hit African nations, such as Uganda, Zaire and Kenya, Haiti is now classified with Thailand and Brazil as hard-hit by the virus, but hardly among the worst AIDS disasters on the globe, Atkinson said. She stressed that the lingering stigma has deeply complicated the job of combatting a disease that is still spreading fast.

“Just getting the Haitian staff here to say the A-word was very difficult,” she said, adding that the Johns Hopkins project deliberately billed itself as a tuberculosis clinic “because otherwise people wouldn’t come. And no one we diagnose as HIV-positive will admit it to their family and friends. Even now, they just don’t want people to know.”

A recent illustration was the death of Master Dji, the father of Creole rap and one of Haiti’s best-known musicians. Although most of his admirers--indeed Haitian society as a whole--strongly suspect he died of AIDS, no one from the family has publicly acknowledged it.

But Atkinson also agreed with American officials that the stigma is only part of a broader problem rooted in the patterns of sexual relationships in a society as deep and complex as Haiti’s, where the spread of AIDS in most recent years has become, as in Africa, a distinctly heterosexual phenomenon.

In Haiti’s native Creole, there are no fewer than three words to describe formal relationships between men and women: There is maryaj , the traditional legal union of a couple. But there is also plase , an accepted sexual partnership outside of marriage, in which the woman does not live with the man but agrees contractually to exchange sex for long-term financial support. There is also a relationship known as vive avec , which describes a union more permanent than plase but one that may or may not involve living together.

The common thread through all three--they often exist simultaneously, with most men and women involved in more than one.

“This business of partners is cultural, it’s anthropological and it’s economic,” an American aid official said. “It’s not at all prostitution. It’s a way of life. And most of the women will say that if she asks her partner to use a condom, he’ll leave her. These are women who survive on these business relationships, usually with several men at the same time.”

These social patterns most likely contribute to the epidemic spread of the disease in recent years into Haiti’s female population, to women like Rita Jean-Gilles and the others dying in the Sisters of Charity ward.

“Here, it’s not homosexuality. It’s not needles,” said Clark. “This is sex. Straight heterosexual transmission. There’s a lot of serial monogamy here. There’s more promiscuity. Women are available for anything, either through money or force. And that’s the big obstacle.”

Clark’s campaign, which has sold more than 8 million condoms since it began three years ago, is probably one of the best long-term solutions to Haiti’s AIDS problem, according to U.S. aid officials who support it with an average of $350,000 a year. The company, Washington-based Population Services International, now runs anti-AIDS projects with U.S. government subsidies in more than 20 nations.

The company has succeeded in making its “Panther” condom not only a household word but standard bedroom fare in many Haitian homes with an advertising campaign--developed by a Haitian ad agency--that uses the popular sport of soccer.

The symbol of PSI’s condom, sold for 2 cents each at 700 retail outlets nationwide, is a goalkeeper, who appears with a panther in more than a thousand radio and television spots per month and on billboards nationwide along with the words: “Don’t take a hit! Don’t get scored on! AIDS doesn’t get in.”

Looking to the future fight against AIDS under President Aristide, Clark and other experts see the potential for more struggles.

As Aristide’s government begins to rebuild an effective health ministry--with the backing of several million dollars in American aid--Clark and others fear that the government of a former priest may well object to the massive, condom-marketing scheme. Neither Aristide nor his new Cabinet has commented publicly on AIDS during their first few weeks in power. “We don’t know what’s going to happen with this government on all issues of family planning,” one U.S. health official said, noting that one of Haiti’s archbishops publicly reprimanded children for singing the Panther condom jingle in class. “It’s clearly an area where we’re keeping our feelers out.”

But echoing the words of most AIDS workers in Haiti, Clark simply concluded, “I can’t imagine any government not realizing this is an epidemic that is killing its people.”