From The New York Times, March 23, 2003

Trees in Haiti Fall Victim to Poverty of the People


FORÊT DES PINS, Haiti, March 22 — In a musty shop near the capital's dilapidated cemetery, Josue Termidor takes a rasp, gently sanding a coffin made of avocado tree planks. A decade ago, the coffin would have been carved from heavy mahogany.

"All the good wood is gone," says Mr. Termidor, 32, his fingernails caked with putty used to seal the brittle wood. "It's got harder to make a living, and the lack of wood makes families disappointed and the dead angry."

Once blanketed by lush forests, Haiti is now nearly 90 percent deforested. Competing against a demand that has far exceeded supply, the Caribbean nation loses more than 30 million trees a year to provide wood, fuel and work to a desperate population.

"The peasants cutting down the trees make even less," added Mr. Termidor, flanked by a metallic mauve "tête-boeuf" or first-class coffin.

Haiti's president, Jean-Bertrand Aristide, leader of the poorest nation in the Western Hemisphere, has been unable to tackle poverty, unemployment and political instability, let alone the environmental tragedy.

Efforts have been stymied by rivalries between the government and opposition, with millions of dollars in international aid suspended since flawed 2000 legislative elections. Some was earmarked for environmental projects.

"We face a total ecological disaster," Mr. Aristide said last month. "Misery and the lack of education are making people cut more trees."

Money would allow the government to prosecute illegal loggers and pursue and an aggressive literacy plan to teach people the value of trees, he said.

But trees are vulnerable even at Forêt des Pins, the Pine Forest National Park that is one of Haiti's few protected areas.

A "No Tree Cutting" sign hangs above the entrance to the forest, on the border with the Dominican Republic. Trash is scattered about the giant pine trees, which have deep hack marks in their thin trunks. Loggers make nightly journeys here, slowly hacking away at trees until they fall. The next day, they are on a truck to the capital, Port-au-Prince.

"The problem is simple, just stop cutting down the trees," said Joel Joseph, a forest ranger with the Ministry of Agriculture. "But you have to have the resources to educate people and to enforce the law. I say the problem is simple, but deep down I know we're headed for disaster."

In 12 years Mr. Joseph has watched his forest disappear, to 34,580 acres from 93,860. Roadblocks are set up to stop illegal loggers, and their logs are confiscated. But even if they are caught, the rangers lack the power to arrest them.

Political instability has also accentuated the despair, pushing hundreds to the forests for a source of income.

"When there are political problems in Port-au-Prince, more people come up here with chain saws," Mr. Joseph said.

The scarcity also affects farmers. With no tree roots to hold the soil, topsoil has disappeared and fewer vegetables can grow. Some farmers also report a change in weather.

"Because there are fewer trees, there's also less rain," said a 40-year-old farmer, Cedner Jean. "Dew allows us to grow cabbage, potatoes and beans but we can't grow anything else anymore."

It takes a dozen planks, which cost $60, to make Mr. Termidor's shoddy casket. Each sells for an average of $200, and with the profit he pays seven employees, the rent and transport for the planks.

Coffins are potent symbols in Haiti, where properly burying the dead is tantamount to ensuring protection for the living. But without wood, Mr. Termidor risks angering grieving families and his employees.

For Mr. Termidor, "It's a good business because more people are dying." When he began 15 years ago he made nine coffins a month. Now he makes 15. "But without trees," he said, "we're all going to end up dead."

From the New York Times, November 29, 2003

Rural Haitians Are Vanguard in AIDS Battle


CANGE, Haiti — In the cool mist of daybreak, hundreds of villagers fanned out across the forsaken reaches of this nation's remote interior, fording rivers swollen by torrential rains, slogging through muddy cornfields and clambering up slippery mountainsides to reach people sickened by AIDS.

At each home, they handed out the little white pills that have brought their neighbors, wasted by the disease, back to robust life.

"If the medicines weren't here, I'd be dead," said Manesse Gracia, 39, a mother of six who was plump in a workday dress the color of orange sherbet. "My children would live in destitution. My husband is a farmer, but the earth gives back nothing."

Mrs. Gracia is part of a pioneering program run here by a Boston-based nonprofit group, Partners in Health, that has become an influential model in the frenetic global race to expand drug treatment in dozens of poor countries.

More than two decades into the pandemic, 22 million people have died of AIDS, and 40 million people are infected with H.I.V., the virus that causes AIDS. Millions will perish next year unless they get the medicines.

"Bringing antiretroviral therapy to all who need it is the most medically challenging task that the world has ever taken on," said Dr. Richard Feachem, executive director of the Geneva-based Global Fund to Fight AIDS, Tuberculosis and Malaria.

The fund has approved $800 million for AIDS treatment, but that is only enough to supply antiretroviral drugs to just 700,000 people in five years.

The World Bank is increasing support, and the United States Congress is close to appropriating about $2 billion, more than half of it for treatment.

No program to treat people in the poorest countries has more intrigued experts than the one started in Haiti by Partners in Health — which has succeeded by enlisting help from hundreds among Haiti's vast pool of unemployed and underemployed workers.

It is the rainy season now. So each morning and evening, 700 villagers strike out across dirt roads turned into a morass of mud and dung to deliver medicines to people with AIDS and tuberculosis. They tramp through muck and wade through streams on foot; a lucky few sit atop mules or donkeys.

Margareth Guerrier, wearing a jaunty, broad-brimmed hat, set out on a recent morning from her small concrete house, threading her way past squatters' shacks up a steep, treacherously slick mountain.

At the top, she stopped at a small house and took the AIDS medicines from a black case slung over her shoulder. A 9-year-old girl named Fanise, ready for school in a navy dress, swallowed her pills dutifully as her grandmother looked on.

Then Mrs. Guerrier walked on to deliver pills to another grandmother, two mothers and a father. "There were some among them who seemed more dead than alive," she said. "When they start taking their medicines, they get better."

The AIDS treatment program here, one of the first of its kind in the world, was started by Dr. Paul Farmer, an American, and the group he founded, Partners in Health. It began giving antiretroviral drugs to patients here in 1999, when such efforts were virtually unknown.

"We didn't do it to be a model program," said Dr. Farmer, 44, a Harvard medical professor and anthropologist, who is also the subject of a recent book, "Mountains Beyond Mountains," by Tracy Kidder. "We did it because people were croaking."

Adeline Merçon, who tested positive for H.I.V. in 1991, took a terrible turn for the worse in 1999. When Dr. Farmer hiked through jagged hills to her home, he found her bedridden and withered to about half her usual weight. Her father drew him outside to the rickety stoop and showed him the planks he had gathered to build her coffin.

Dr. Farmer promised to return with medicines to save her. Back in Boston, he scavenged drugs from AIDS patients, doctors and clinics. Partners in Health bought more with money donated by Thomas J. White, a retired Boston businessman, and raised yet more cash by selling its headquarters in Cambridge.

"We couldn't get anyone to support us," Dr. Farmer said. "In 1998, 1999 and 2000, we went to Unaids, the World Health Organization and the World Bank and they said treatment is not cost effective or sustainable. We went to some of the drug companies and asked, `Can we have medicines?' Every single one turned us down."

In the early days, Dr. Farmer carried the pills back to Haiti in suitcases.

On Oct. 28, 1999, a shrunken Mrs. Merçon, weighing only 69 pounds, was brought to the hospital here on a stretcher. She was put on the drugs. "I haven't been sick since," said Mrs. Merçon, 37, who now weighs 120 pounds.

The Spartan model of care used by Partners in Health was born of necessity, but its very spareness is now seen as a virtue by many experts who want the scarce dollars for treatment to stretch as far as possible. Doctors here grafted AIDS treatment efforts onto the existing program for tuberculosis control.

AIDS patients, who will have to take the drugs daily for the rest of their lives, are visited in their homes every morning and evening by a health worker who hands out pills and watches as they are gulped down. Ensuring that the medicines are taken properly reduces the risk that drug-resistant strains of H.I.V. will emerge.

One of the biggest obstacles to rapid expansion of treatment in poor countries is the extreme scarcity of doctors, nurses and high-tech equipment. And the program here has minimized reliance on them. Generally, there are no lab tests done once treatment begins. The only monitor is a scale to weigh patients monthly.

Peasants have been trained to dispense the medicines, draw blood, take X-rays, clean bedpans, measure vital signs and spread the word about condoms preventing H.I.V. infection. Most of the workers who visit patients' homes are paid a small stipend of $38 a month.

Last year, Partners in Health won a $13 million grant from the Global Fund — money now being used to build clinics, laboratories and drug warehouses, and to install generators and satellite dishes in a region largely bereft of electricity and phones.

While other countries can copy the Partners in Health model, they cannot clone Dr. Farmer, a charismatic and chatty healer, and the small, idealistic band of American doctors he has brought to Haiti.

As Dr. Farmer, tall and whippet thin, drove through a village one recent day, jouncing over boulders and crevasses, a low murmur wafted in the window along with the dust. "Paul, Paul, Paul," chanted the women peddling wares at the roadside.

Dr. Farmer has been here since he was in his 20's. He lives most of the year in Cange, a squatter settlement, and regularly commutes about 35 miles — three hours over some of the worst roads in the world — to reach the airport in Port au Prince before flying on to Boston and his teaching job at Harvard.

The example set by Dr. Farmer has helped inspire a similar dedication in Haitian colleagues.

"When I was in my family planning residency, I heard about this white doctor who visits sick people in their homes," said Dr. Roland Desiré. "I'm from a peasant family myself. I came to see what he was doing." Dr. Farmer listened to the young doctor, choking back tears.

He had made this recent visit to the group's clinic in Lascahobas hobbling on crutches. In August, Dr. Farmer broke his leg in a bad fall while hiking uphill in a drenching rain to reach a patient. Surgeons sawed his thigh bone in half and put in a titanium plate to repair it.

With his slight build and boyish face, Dr. Desiré, 31, looks more like a laid-back high school student in his jeans and T-shirt than a briskly efficient doctor.

Among those who had come from great distances to see him in Lascahobas were two women — symbols of how far Haiti still has to go and of how far it has come.

Imitane Pierre had brought her baby daughter Francesca from Port au Prince. Both are H.I.V.-positive, and Francesca had developed painful lesions on her face. Hospitals in the capital had turned them away because the mother was too poor to pay. After two weeks in the clinic in Lascahobas, the bright-eyed girl had gotten better. But now she and her mother had to return to Ms. Pierre's other children in Port au Prince, where treatment programs are not yet established.

"We send them home, but who will take care of them?" Dr. Desiré asked. "There's no one."

Later that day, the doctor turned to Ipoline Occeus, 26. He had to break the news that she was H.I.V.-positive but he coupled it with hope, because she lives in the area served by the clinic.

"You can die from it," she whispered.

In most developing countries, Dr. Desiré's diagnosis would indeed have been a death sentence. But he replied with the words that promised her life: We have the medicines. We can treat you.