To view "Dapre Nou," an earlier short film by Amelia Shaw and her colleagues from Haiti's Agence des Jeunes Producteurs, visit the NPR website.

A film to finish

Most descriptions of Haiti include the phrases “poorest nation,” “ravaged by dictators” or “highest AIDS rate.” These are all true. But to public health alumna and documentary filmmaker Amelia Shaw, there is really only one way to describe Haiti: the land where magic and danger collide.

A letter from Haiti

Text and video stills by Amelia Shaw, M.P.H. ’03

The sun rises on Airport Road, a bustling thoroughfare in Port-au-Prince. My assistant, Moliere Jean, is driving and Liony Accelus, an HIV/AIDS counselor, is in the back seat. We are going to meet Liony’s Uncle Big, a famous voodoo doctor four hours away in Haiti’s breadbasket, the Artibonite Valley.

The radio blares about today’s demonstration against the government. It’s early February and for three months students have demanded the resignation of President Jean-Bertrand Aristide. Their cry has been taken up by business leaders and civil society, who say Aristide is responsible for the disappearance of journalists, the death of the economy and violent attacks on peaceful protesters. But most people are just angry at being poor. When Aristide became president in 1994 most Haitians believed that this priest from the slums would lift them out of poverty. Yet most Haitians have only gotten poorer; today more than 80 percent of Haitians live in poverty and many of them blame Aristide.

Moliere winces and shakes his head. Forty people have been killed and hundreds wounded in antigovernment demonstrations. It has become increasingly difficult to work in Port-au-Prince. More than once Moliere and I have hidden in an alley or screeched up the road in reverse because demonstrations disintegrated into a storm of tear gas, stones and bullets as protesters clashed with riot police or Aristide’s armed supporters, known locally as chimères. I look out the window and wonder what today’s demonstrations will bring.

I first went to Haiti as a Yale student on a Downs Fellowship in the summer of 2002, to coordinate a film project about AIDS and social stigma. Due to funding problems, the project was never completed. I returned to Yale to finish master’s degrees in public health and African studies, yet I could not let go of my memories of Haiti and her courageous HIV community.

Right before I graduated in May 2003 I won a Fulbright Scholarship, and that fall I touched down in Port-au-Prince. “I made it,” I kept thinking, and was both exhilarated and overwhelmed. I had worked as a summer intern at National Public Radio (NPR), but I had never made a film before. Making films, I felt, couldn’t be that different from making radio. The trick is to tell a good story.

I wanted to record the stories of people living with HIV/AIDS, and distribute them in Haiti as a way to reduce stigma and discrimination. Haiti’s national television network was behind me, as were international organizations willing to use the videos in outreach campaigns. In a country where almost half of the people cannot read or write, videos and group discussions can break the silence about AIDS.

Over six months, I filmed dozens of men and women— some of whom hid their faces—as they shared a bit of their lives. Some spoke of their fear of orphaning their children, others of their shame at public humiliation, but most spoke of their desire to live and do a little bit of good in the world.

I met Liony through the small, vocal, HIV-positive network in Port-au-Prince. Liony is unforgettable. Tall, dapper, with a wife and a handful of children, he has a talent for making people listen. He spends most of his time working in a grass-roots organization as one of Port-au-Prince’s only AIDS counselors.

“People think I am a curiosity,” he says, chuckling. “Sometimes I sit for hours on my doorstep and answer people’s questions. … Yes, I still live with my wife, yes we eat the same food, yes my kids play with other kids. Do I sleep with her?” He winks and laughs. “Yes I do, with condoms of course. … though not so much anymore. I need to keep my strength, mon cher!”

Liony gets free antiretrovirals (ARVs) at the Haitian Study Group on Kaposi’s Sarcoma and Opportunistic Infection (GHESKIO), one of two research centers in Haiti that distribute medicine to people with full-blown AIDS. Haiti has about 400,000 AIDS cases in a population of 8.2 million, yet only 1 percent receive AIDS drugs, either through GHESKIO in Port-au-Prince or the Zanmi Lasante clinic in central Haiti run by Paul Farmer, M.D., Ph.D. This may soon change. With millions of dollars pouring in from the Global Fund To Fight AIDS, Tuberculosis and Malaria as well as President Bush’s Emergency Plan for AIDS Relief, more than 30 percent of Haiti’s AIDS patients—120,000 people—are expected to receive ARV treatment in the next five years.

“You know, if I hadn’t gone to the houngan two years ago, I probably never would have gotten so sick,” Liony says, shaking his head, “But then again I wouldn’t be on treatment now either.”

A houngan is a voodoo doctor. And when people are sick in rural Haiti, the houngan is usually the first person they’ll see. Most rural Haitians believe that illness is the result of evil, caused by a vengeful or jealous neighbor. And with only 2.5 physicians per 10,000 people, health care in rural areas is not always an option. So the houngan becomes a logical place to seek help. Unfortunately for people with AIDS, the treatment they get from a houngan usually makes their situation worse.

“I had to drink this brown liquid and sleep outside for days at a time. I spent my savings on it. And in the end, man, I just got sicker and poorer,” Liony says. After a few weeks, Liony’s father found him weak and shivering, and carried him to a health clinic.

“I had pneumonia,” Liony says. “But the good thing is, I went on medications.” When Liony’s doctor saw that his T-cell count was below 200, he referred Liony to GHESKIO for treatment.

“AIDS is AIDS. A curse is a curse.”
We enter the sprawl of Cité Soleil, the slum on the edge of Port-au-Prince famed for its mind-bending poverty and patrolling chimères. We weave through crowds of people stepping crisply over open sewage. A lucky few are on their way to jobs in the industrial complex, assembling baseballs or T-shirts for a buck fifty a day. In a country where unemployment soars to 70 percent, $1.50 seems like a godsend. We come to a roadblock guarded by kids with dreds, and Moliere instinctively turns down the radio and flashes an open palm. “Cinq ans!” the hand says, “Five years! Five more years for Aristide!” Moliere doesn’t support Aristide, but here an open palm is a ticket to safety.

We leave Cité Soleil and drive over broken roads, past fishing villages, rice paddies and women hawking peanuts and melons. Then the land dries up and the dust rises.

“See those up there?” Liony says, pointing to little shacks on the hillsides. “Those are all peristyles, the temples where houngans receive their clients.” Peristyles dot the naked hillsides as far as the eye can see.

We walk a maze of dusty footpaths to Big’s peristyle. It is a work of art. The temple walls are covered with murals of saints, serpents and mermaids, and the air flutters under a canopy of colored streamers. Big is sitting outside on a stool in front of a large painting of the Virgin Mary and a rainbow.

“Uncle Big!” Liony calls out, and Big chuckles and spits. He has a fat belly and old red eyes. He waves children away and gestures for me to sit. I ask him what he knows about AIDS. His response leaves me floored.

“AIDS is AIDS. A curse is a curse. Now diarrhea can be supernatural. But AIDS …” Big pauses to spit in the dirt, “nope, AIDS can’t.”

Most houngans claim they can cure the “AIDS curse,” called mò sida in Creole. They say you get mò sida when your enemy makes a powder out of someone who died from AIDS and blows it on you. If Big thinks someone might have AIDS, I ask, what does he tell them?

“What can I tell them? I say, did you go to the doctor … no? Well then go and get an HIV test. Then you can come back.”

In Haiti, this is unheard of. Most people prefer not to know their serostatus—a positive result hangs like a death sentence. But being told to get an HIV test by a houngan could be just the encouragement people need to seek testing and counseling.

“If the test is positive, I say there is nothing more I can do.” Big raises his hands in the air. “Because the problem isn’t mystical, it’s medical. And they need to go see a medical doctor to resolve it. I can’t cure AIDS!”

But what about all the houngans who say they can?

“Ah! It’s all bluff! Bluff!” Big is clearly upset by the question. “Houngans can’t treat AIDS! I mean, look around, now honestly, what would I use to treat AIDS?”

I do look around. I see a skull lying on a miniature coffin, a brown baby doll head, an American flag and three plastic coke bottles. Less than 20 years ago scientists were asking themselves the same question—what can we use to treat AIDS? Well, we’ve got our answer. Treatment exists. Now the big question is, how do we get treatment to the people who most need it—poor people living on the margins of global society?

Sitting in Big’s peristyle in the dusty plains of the Artibonite, it dawns on me that for Haiti the answer may sit at the crossroads of public health and voodoo. Public health professionals around the world need to keep advocating for affordable drugs in poor countries. And then they need to collaborate with the people on the ground who really make a difference.

No matter how unorthodox his methods, a guy like Big is saving lives. By affirming the role of medicine in a world dominated by the supernatural, he is directing rural people to the tests and treatment they need. If more houngans follow Big’s lead, Haiti could see a turning point in the fight against AIDS.

A hospital becomes a war zone
On our return the capital disintegrates into chaos.

The radio reports that a student was shot with a tear-gas canister and taken to Canapé Vert hospital for emergency surgery. While doctors are trying to remove the canister from his abdomen, it explodes. I am picturing white smoke pouring out of a wound in a young man’s body. The hospital is evacuated. The student dies. His classmates surround the hospital, enraged.

As the violence escalates I am drawn to epicenters of conflict to film, to record, to try and understand the country. I sometimes want to play reporter, but it isn’t journalism that inspires me—it’s public health. Because journalists are cynical, and I still believe in the power to change.

Moliere and I leave Liony at his house and then go to the hospital. The chain of events is fast and brutal. Students drag abandoned cars into the road and light them on fire. The riot police finger their M16s. Pistols crack on the hillside, and a woman screams, “The chimères are coming down the hill!” The road explodes in a flurry of shouts and lost shoes. The police storm the flaming barricades—sparks fly, bullets fly, students fly or hit the ground and pray.

Rat tat tat tat tat tat tat.

If you have ever stood near machine gun fire, you know the sound: loud, and very, very mean. The hospital becomes a battleground. Patients in white robes running in panic totter and fall in the courtyard. Doctors scream. Students hide and riot police chase them from room to room. In the confusion, a woman is raped on the operating table. She had been recovering from minor surgery; her story was broadcast on that night’s news.

I run through the thick smoke with my camera, and come face to face with a riot police officer in sniper position, his M16 trained on my left shoulder. I feel a hot red point where the bullet would enter. He is screaming at me, and I am paralyzed. When I hear Moliere’s frantic footsteps behind me, I shout the only thing that comes into my head:

“I AM A JOURNALIST! I AM A JOURNALIST!—PLEASE! DON’T SHOOT!” My only proof is my expired intern badge from NPR, but in retrospect, I believe this saves us both. Lucky for me, dead white journalists are bad press for Aristide.

In darkness, a candle brings light
Haitians have a saying: “When you run from the rain you only end up falling in a big river.”

In the weeks that followed, the country crumbled around our ears, and in mid-February the city imploded. People stayed indoors while businesses were looted, neighborhoods were barraged with tear gas and roads blocked by flames. The nights were filled with gunfire and shouts and the days saw hospitals overflowing. Yet the storerooms were bare and many doctors stayed home because, as in the case of Canapé Vert, even the hospital becomes a war zone.

I watched my work become insignificant as people’s conception of risk changed entirely. It is hard to think about AIDS when staring down the barrel of a gun. So while I wasn’t surprised when, a few days before Aristide left the country on February 28, I was told by the U.S. Embassy to evacuate, I was overcome with a feeling of great loss.

But in moments of darkness, one candle brings light.

While I am packing my bags, my cell phone rings. It is Liony.

“Amelia! When are we going back to the Artibonite? We need to film another interview with Big!”

Liony is unstoppable. A group of armed rebels—disgruntled chimères, drug traffickers and convicted criminals—had taken over the Artibonite the week before and were moving south. They have sealed off the country’s northern corridor, setting the stage for a scene Haitians have seen too many times: state decapitation. Whereas over a decade ago, Aristide rose to the presidency on an unprecedented wave of popular support, this week he is about to become just another overthrown dictator in Haiti.

When I tell Liony I’ve been ordered to evacuate, he doesn’t miss a beat.

“Don’t worry, you’ll be back. We have a film to finish.” His voice is both confident and nonchalant. “You know, our film is really going to change the way Haitians think about treating AIDS.”

For the rest of the afternoon, my cell phone does not stop ringing. Liony has mobilized the entire AIDS community to give me a message: “Hey Amelia! Don’t lose hope! You’ll be back—we have a film to finish!” I am touched that they are calling to comfort me—after all, I am the healthy one getting out.

Yet I learned that day that the optimism of HIV-positive Haitians is unbreakable. By force of will, they beat the odds and survive in a world where magic and danger collide—often with deadly consequences. These people are heroes. They are also Haiti’s hidden treasure. Because when the rumbling stops and the smoke clears, Liony and his comrades will be the first to climb from the wreckage. They will smile and rub their hands, ready to rebuild stone by stone. And God willing, I will be there with them too. After all, we do have a film to finish. YM

In late July Yale Medicine received this e-mail from Amelia Shaw:

I arrived in Haiti two days ago. ... It has been an emotional journey. The poverty here is stultifying—it shocks you even when you expect it. Things are much calmer than when I left, but a lot of unreported violent crime occurs in the slums, where most of my friends live. And floods have knocked out parts of their houses, leaving them open to intruders. People seem tired, very weary of “the everyday” in Haiti, which includes the most hair-raising bits and pieces of reality. The money has deflated in value, but prices have not, and a lot of people can’t buy food.

But the good things are there too—the electricity is on most of the time. And the musicians have returned, which is a sign of relative stability. United Nations vehicles are everywhere, and hopefully the police are strengthening in numbers.

I saw Liony today. It was such a happy moment! That has been the best for me, to see the people I have worked with so closely! I am so happy to be back here! It is wonderful, though it also makes my heart bleed.

Amelia Shaw, M.P.H. ’03, graduated from Yale in 2003 with joint master's degrees in public health and African studies. She returned to Haiti in July 2004.

Staying safe abroad

Facing instability like the recent upheaval in Haiti may be the norm rather than the exception for people working in international health, says Frank J. Bia, M.D., M.P.H., FW ’79, co-director of the Yale/Johnson & Johnson Physician Scholars in International Health program, which sends residents to more than 14 countries. “The inherent nature of international health is working in an unstable world,” says Bia, professor of medicine (infectious disease) and laboratory medicine. “It’s unstable because it’s unfair, and I think it’s getting worse.” Increasingly, he said, the world’s poor are becoming aware of “how bad off things really are in terms of the increasingly skewed distribution of both wealth and technological resources.”

Since the international program began in 1981, more than 100 Yale residents have volunteered for a month or two at Haiti’s Hôpital Albert Schweitzer. The program has rarely suspended activities due to turmoil abroad, but temporarily stopped sending physician volunteers to Haiti this year, said program co-director and professor of medicine and public health Michele Barry, M.D., HS ’77. She expected that rotations in Haiti would resume later this year. (Four years ago Yale suspended its program in Zimbabwe in the wake of widespread violence there.)

Second-year resident Emmanuelle Clérismé-Beaty, M.D. ’02, found herself in a strange situation while volunteering in Haiti last January in the weeks preceding the ouster of President Jean-Bertrand Aristide. Although most foreigners felt safe at the hospital, she was harassed by hospital workers who wanted her to join protests against the hospital administration. Clérismé-Beaty, who grew up in Haiti and speaks Creole, was taken for a “local.”

“It got pretty scary,” she recalls. She chose to leave a few days early, catching a ride to the airport before dawn to reduce the danger of being robbed on the road. Clérismé-Beaty feels ambivalent about the experience. “Being there, you knew you were needed, and you were appreciated,” she says, adding, “I didn’t really feel safe.”

For those in charge of sending students and residents abroad, security is always a concern. Summers are nerve-wracking for Curtis L. Patton, Ph.D., head of the Division of Global Health at the School of Public Health. Patton directs the Downs International Health Student Travel Fellowship program, which funds research for about 16 students of public health, nursing and medicine who spend a summer abroad.

He relies on four sources to judge the safety of research sites: advisories from the State Department and the Centers for Disease Control and Prevention, Yale College’s list of countries declared off-limits to undergraduates and information gleaned directly from people at the sites. This spring he advised one student to avoid Haiti. She went anyway, and “she seems to be fine,” Patton reported in mid-summer. He barred another student from studying diarrheal diseases in Iraq; she went to Tanzania instead.

“I have my heart in my throat all summer until they return,” says Patton.

—Cathy Shufro