A Sour Taste on the Sugar Plantations

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Science  28 Jul 2006:
Vol. 313, Issue 5786, pp. 473-475
DOI: 10.1126/science.313.5786.473

Haiti's wealthier next-door neighbor is struggling to provide treatment to many HIV-infected people, and the problem's especially acute on the bateyes

SANTO DOMINGO, SAN PEDRO DE MACORÍS, MONTE PLATA, DOMINICAN REPUBLIC—The Dominican Republic shares the island of Hispaniola with Haiti, but the two countries could be across the globe from each other. Dominicans are Latin and pride themselves on their Spanish roots, whereas Haitians speak Creole and are largely descendents of freed African slaves. As tourists flock to the Dominican Republic each year, Haiti has seen its tourist industry evaporate over the past 2 decades. Dominicans have a vastly higher gross domestic product than their Haitian neighbors, whose average life expectancy is nearly 20 years shorter. And it follows that the two countries have starkly different HIV/AIDS epidemics that have attracted dramatically different responses. In an unusual twist, poorer and less stable Haiti is being celebrated for its pathbreaking AIDS efforts, largely led by two prominent nongovernmental organizations (NGOs). The Dominican Republic, on the other hand, is being lambasted for its shortcomings—the result, critics say, of government disinterest and outright obstructionism.

At the end of 2005, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that the virus had infected 1.1% of the adults in the Dominican Republic—a prevalence less than one-third of Haiti's. But according to insiders and outsiders alike, the Dominican Republic's HIV/AIDS programs in comparison are sorely lacking. “It's 1000 times better in Haiti,” says Keith Joseph, a clinician at Columbia University who has done HIV/AIDS care in both countries. “It's astounding that a place with so much is unable to get things going.”

Critical care.

Sister Rivera provides bateyes with some medicines but does not have the anti-HIV or TB drugs that Miguel “Bebo” de Jesus needs.

Nowhere is this more evident than in the bateyes, where the Dominican epidemic is disproportionately concentrated. Originally built to house workers from Haiti on the sugar cane plantations, bateyes have become shantytowns largely filled with descendents of the original migrants or new Haitian immigrants. “People with AIDS in the bateyes are just dying without any kind of help,” says Sister Concepcion Rivera, a nurse with the Sisters of Charity who runs a mobile health clinic.

The clinic attempts to care for people living in the many bateyes near San Pedro de Macorís, a port city on the southeast coast of the Dominican Republic. Although the van is stocked like a minipharmacy, Rivera, who has a master's degree in bioethics, on this March day has no anti-HIV drugs, nor can she treat tuberculosis, one of the biggest killers of people with AIDS. “On paper, the government does things, but in practice, they really provide nothing,” says Rivera, adding that for the past 3 months the government has not even paid the small subsidy it promised her group.

Although the Dominican Republic now offers anti-HIV drugs in major cities such as Santo Domingo, Rivera's complaint repeatedly surfaces in the bateyes. Government studies showed that adult HIV prevalence was 5% in the bateyes in 2002 and jumped as high as 12% in men between 40 and 44 years old. And even where antiretroviral drugs are available, the government has faced intense criticism for moving slowly. UNAIDS estimates that 17,000 Dominicans need anti-HIV drugs, but as of December 2005, only 2500 received them through public programs.

Still, NGOs have made some headway in both prevention and treatment programs. Family Health International (FHI), which is funded by the U.S. government, supports several of these programs, but its director in Santo Domingo, Judith Timyan, laments that this is necessary. “This country's relatively rich and has a huge middle class,” says Timyan, who has since left to do HIV/AIDS work in Haiti. “The Dominican Republic should have grown out of its need for help.”

Bad blood

In 1821, Haiti invaded the Dominican Republic and ruled for 22 years, creating bad blood that has yet to disappear. “The Dominican ruling class will tell you everything that's going wrong with the country is the fault of Haiti,” says Geo Ripley, an ethnographer and artist who is a consultant on bateyes to the United Nations.

This bad blood in part explains the government's limited response to the problem in the bateyes and also discourages any attempt to replicate Haiti's HIV/AIDS successes. “If you say to the Dominican people, ‘We can learn from Haiti,’ they'd say, ‘We don't have anything to learn from them,’” says Eddy Perez-Then, a clinician who is now completing a Ph.D. dissertation about bateyes near the southwestern city of Barahona.

As in Haiti, the Dominican epidemic initially involved men who have sex with men, but it has gradually become more “feminized” and driven by heterosexual sex. This is reflected in the ratio of men with AIDS to women, which in 1986 was 3.63:1 and today is nearing 1:1. Government researchers estimate that 78% of infections now occur through heterosexual sex, some of which is linked to a booming sex trade (see sidebar): Some sex-worker communities have had documented prevalence above 12%.

Cultural mores regarding promiscuity may partly explain why the bateyes and Haiti have similarly high prevalences, but many experts suggest that's too simplistic a view. Nicomedes “Pepe” Castro, who has worked with bateyes for 28 years, notes that in the last century the sugar industry primarily attracted male migrants. “Bateyes were the only part of the country where the proportion of men was higher than women: 4 to 1.” This, in turn, created more sharing of partners and a greater market for sex workers. With the demise of the sugar cane industry, Antonio de Moya, an epidemiologist and anthropologist who works with COPRESIDA—the presidential commission on AIDS—says an increasing number of young Haitians who immigrate are becoming sex workers themselves. Finally, and perhaps most important, the rampant poverty in the bateyes facilitates HIV's spread, which is tied to a lack of education and less access to prevention tools such as condoms and treatment of other sexually transmitted diseases.

Epidemiologist William Duke, who works with FHI, says it's unclear whether the Dominican epidemic is growing, shrinking, or stabilizing. “In general, our surveillance is very weak in the public health sector,” says Duke. “When you go outside of the capital, it's difficult to catch the data.” Although Haiti's surveillance surely has gaps, NGOs, government-run prenatal clinics, and outside consultants have reliably tracked that epidemic.

Whereas Haiti in 2002 marshaled the strong support of then-First Lady Mildred Aristide and became one of the first countries to secure a grant from the Global Fund to Fight AIDS, Tuberculosis, and Malaria to buy anti-HIV drugs, the Dominican Republic did not make a similar deal until 2004. Haiti exceeded its targets for delivering antiretroviral drugs to people in need; the Dominican Republic, in contrast, has repeatedly lowered its sights.

Even today, one NGO in Santo Domingo, the Instituto Dominicano de Estudios Virologicos, provides care for 20% of the people receiving anti-HIV drugs. Ellen Koenig, an American clinician who has lived in the country since 1969 and started the institute, assails the attitude of the government that recently left office. “There were more people in the country living from AIDS than with AIDS,” charges Koenig. “It was ridiculous.”

Perez-Then says about 25% of the bateyes do have government clinics nearby, but the residents don't use them much. “They're afraid to go,” he says. In some cases, they are recent Haitian immigrants who only speak Creole. Others do not have proper documentation or fear discrimination.

Perez-Then worries, too, about the complexity of treating HIV-infected people and the quality of care available at government-run programs. The Dominican Republic has one of the highest rates of drug-resistant tuberculosis in the world, which occurs when people start treatment but then miss doses of their pills. The same could easily happen with antiretroviral drugs, he says.

Taking it home

Weeds and scrub brush have overgrown the old sugar cane fields near Batey Cinco Casas, located in Monte Plata province a few hours' drive from Santo Domingo. But there's some new growth that has thrilled the residents: a clinic built by the Batey Relief Alliance. Similarly, the Christian relief group World Vision has built a clinic in Batey 6 near Barahona. Both clinics have a limited ability to help HIV-infected people, but they do what they can. In March, for instance, the Batey Relief Alliance was regularly transporting 28 HIV-infected people from the Monte Plata area to Santo Domingo to receive anti-HIV drugs. Many more need transportation, says Maria Virtudes Berroa, who runs the relief association's Santo Domingo office, but the organization doesn't have enough money. One of those is an emaciated man they recently found dying from late-stage AIDS. Like hundreds of thousands of Haitians before him, Jean-Claude Delinua, 31, moved to the Dominican Republic 11 years ago to cut cane. Delinua now lives on the edge of a fallow sugar cane plantation in a one-room shack. He rarely leaves his hammock, which is made from a pig-feed sack. He has no job, no family, no possessions beyond the clothes he wears, toiletries, a paperback, and a photograph of himself 8 months earlier when he was buff and hale. Delinua, who speaks in Creole, says he knows about the care offered in his home village in Haiti's Central Plateau. “I'd like to go back,” says Delinua. “But I don't have the money, and I'm not sure my family would receive me.”

Graham Greene, author of the classic novel about Haiti called The Comedians, once wrote that it was impossible to exaggerate the country's poverty. For HIV-infected people like Jean-Claude Delinua, it's all too easy to exaggerate the prosperity of the Dominican Republic.

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