Route Nationale #2 – Medicine, Mangoes and a Mangled Machine

     So once again I found myself sitting in the back of the sisters’ Land Cruiser speeding west down the National Route 2, headed for Baradères. Father Jacques had come to Port-au-Prince the day before to pick up our team from the airport. Three parishioners flew in for the graduation ceremony for the Philo class from our school, the College St. Jean Baptiste in Baradères. The trip had turned into a mini-medical mission because of the chikungunya epidemic that had gripped the island. Our team was bringing down large three bags each of acetaminophen to treat the symptoms of Chik fever. Their flight was arriving at 12:40 pm. Father Jacques and Kendol, Sister Denise’s driver, would get them at the airport and then pick me up at Christianville on the way to Baradères. At 2:45pm I received a phone call from Father Jacques. He had picked up the team and they were stuck in Carrefour. Traffic. Maybe another hour. At 4:00pm, another call. They were here. I gathered my backpack and the extra eight giant bottles of acetaminophen that I had brought down (part of our church’s generous donations) for treating the Chik fever and headed out the door. We got on the road at 4:15pm. I figured about a five-hour drive so we would be on the mountain road up to Baradères after dark. Just like my first trip there.

     It is World Cup time and as we drove up to Baradères, Kenol had the Land Cruiser’s radio dialed into the Holland – Spain match. The announcer gave the play-by-play in French in the typically animated fashion that is football broadcasting. When a goal was scored, the classic “GOOOOOOOOOOOOOOOOOOOOOOOOOOOAL”filled the inside of the Land Cruiser. Holland crushed Spain 5-1 so we heard plenty of, well I’m not going to type it again.

     We stopped at Eva’s for gas, bread, and drinks. Father Jacques picked up eight loaves of sliced bread. The inside of the Land Cruiser was already filled with our team’s bags and food that Father Jacques has bought in PauP. Supplies were also lashed onto the Land Cruiser’s roof. Cynthia sat in front next to Kenol, the driver. Jacques, Stephanie and I sat on the bench seats in back. Two cases of Prestige were stored under the benches.

     The traffic got heavier and slowed down as we entered Carrefour du Fort. More than a dozen vendors lined both sides of the Route National #2 in front of the Total gas station. They were all selling mangoes. We came to a stop and as we did, about six vendors (all women; I don’t recall ever seeing a man selling fruit or vegetables on the road or in the market) raced up to the Land Cruiser carrying their mangoes neatly piled in pyramids in shallow wicker baskets. Jacques carefully opened up the rear door of the Land Cruiser and examined the mangoes of the first (lucky) woman who presented her basket. Jacques picked out two bruised mangoes and told the woman that he did not want those but would take the rest. She quickly agreed but said that she had other, nicer looking mangoes she would give him in place of the two bruised ones. Jacques placed the mangoes he wanted in a black plastic bag that the woman had given him and the woman returned to her stand to find the nicer ones. A second woman took her place in front the Land Cruiser's rear door. Jacques examined another basket of mangoes and bought them. The first woman returned with the new mangoes and Jacques paid her the 100 gourdes for all six large beautiful fruits. Mangoes always seem to be in season somewhere in Haiti and the country is full of them. Mangoes fall out of the trees in C’ville when I walk to the lab. They lie on the ground waiting for someone to collect them or they start rotting in the hot sun. I wonder, as I often do during these trips, why there is no mango export industry. The fruit appears plentiful and it is not possible that Haitians are consuming all the mangoes produced on the island. Father Jacques told me later that Haiti does export mangoes. Nevertheless, between 4 and 5 million tons of mangoes go uncollected, unsold, uneaten (all of the above?) and rot on the ground every year. Why can’t they do better? It is a plentiful natural resource and another paradox of Haiti. A bountiful fruit yet so much waste.

     We slowed down as we drove through Miragoâne. Jacques was on his cell phone. We stopped momentarily. Then we drove on. We stopped, again. Jacques threw open the rear door of the Land Cruiser and Father Castille climbed in with his backpack. He was returning from a wedding and had spent the night at his mother’s house. As usual, vehicles always fill up on any trip. We drove on and a few minutes later we slowed down again and Father Castille told Kendol where to stop. He opened the rear door and a tall man handed Father Castille his clothes. Jackets, shirts and pants cleaned and pressed and on hangers covered with a clear plastic bag. It was just like picking up your dry cleaning back in Silver Spring.

     We sped along the National Route 2 as it turned south into the mountains towards the opposite coast. Suddenly Kenol slowed down and came to a full stop. A truck was stopped in our lane facing us. There was an accident. A crowd of Haitians was gathered on the right side of the road around a blue pickup truck that had run off the road into a drainage ditch. The truck’s driver gestured to Kenol to back up and he climbed into his vehicle. I could see that the truck was not part of the accident as I first thought but that it had a towline attached to the pickup that was in the ditch. We backed up and the truck driver slowly put his truck in gear and moved forward. The towline grew taut and the crushed pickup truck slowly rolled backwards out of the ditch. The truck stopped and the driver undid the towline. It looked like an old fire hose that was just tied from one vehicle to the other. The truck moved away and Kendol slowly advanced the Land Cruiser past the accident scene. The crowd grew more animated. As we drove past, I saw a shirtless young man swinging a sledgehammer on the passenger side of the crushed pickup. A woman was trapped inside and this was their only means of extricating her. Kendol was talking almost non-stop now on his cell phone. He was telling his friends about how this pickup truck had sped past us earlier on the road. It was driving much too fast, he said and now the pickup was smashed up on the side of the road. I wondered how many times a day this same scene plays out in Haiti, on this same road and on other roads in the country. I have seen it before but usually the twisted remains of the accident. I had never arrived on the scene so soon after an accident. We all witnessed the response. There were Haitians helping Haitians. Regular people. There were no police to direct traffic and coordinate a rescue response. No fire trucks, no EMTs or rescue vehicles. No “jaws-of-life” to extricate the trapped woman; just a man with a sledgehammer. I saw an ambulance drive away shortly after we arrived but it appeared to be carrying passengers, not accident victims. I could not be sure. As we drove down the road past the accident scene, a man was placing large leafy branches he had cut down from a tree in the middle of the road. This was the Haitian highway equivalent of safety flares or orange cones. It was to warn drivers of an accident ahead. We drove on. Kendol had one hand on the steering wheel and the other on his cell phone complaining about bad drivers and bad outcomes.

Chilling with Customs in PAP

     I planned to fly back to Haiti for a week in mid-June to meet with some people about my project and also to attend a graduation ceremony at the school that my church supports in Baradères. The beast arrived in my lab in Bethesda three days before my departure. The beast is the GeneXpert IV, a real-time PCR machine that I was going to use for rapid diagnosis of Chlamydia and gonorrhea. The GeneXpert is a loaner from Cepheid, the manufacturer, who agreed to lend me the instrument for one year for my STI surveillance study. The instrument itself is not large but with its shipping case, it was a beast. The wheeled shipping case is a heavy black plastic cube about 18 x 20 x 24 and weighing 67 lbs. Perfect for safely shipping the instrument but it proved to be a red flag for Haitian customs.

GeneXpert IVV shown here with desktop computer

     As is our tradition, early Thursday morning Pierre drove me to DCA for my flight to Miami. I had no problem checking the beast at Reagan National. Overweight? No problem. You just pay extra, which I did. During the flight, I tried to think about what might happen at customs in PAP. I had never been stopped there before and I was almost certain that the beast would be my ticket to a special interview with a customs agent. It was.

     I collected my suitcase and the beast in baggage claim and got in the line that moved slowly past a customs agent who collected our papers and then directed people (seemingly at random) to another room for bag inspection. I was selected. While I waited for a customs agent to appear, I watched a family of five being questioned about what they were bringing into Haiti. Acetaminophen, the father explained as the rest of the family looked on anxiously. The customs agent pulled out a Costco-size bottle of acetaminophen from their open suitcase. I had eight of the exact same bottle in my suitcase. And I had the beast. This could be bad. The customs agent asked a few more questions and let the family go.

     Soon a young man appeared. It was my turn. He asked me in English to open my suitcase. I did and he was soon looking intently at the top layer of 30 boxes of rapid diagnostic test kits for syphilis. What are these he asked? Test kits for syphilis, I answered. He directed me to open a box. I did and he looked curiously at the individual packets and then pulled one out and inspected it. He returned it to the box and asked if I was a doctor. Yes (why not? Otherwise it gets too complicated).  Okay. He told me to close the suitcase and turned his attention to the beast. He told me to open the case. I carefully undid the latches and soon the customs agent was staring down at the beast.

The beast in its box

I told him what it was and explained that it was on loan from the manufacturer and that it was for medical purposes. He looked at the laptop that comes with the beast and informed me that I needed to declare the beast and pay customs duty. How much? I asked. It depends on how much the beast is worth, he replied. I have no idea, I said; it is on loan. I showed him the contract with the manufacturer that explained that the beast was on loan to me. It was not enough. The young man wanted to know how much the instrument cost so that he could calculate the customs duty. He pulled out a smart phone and asked me how to spell the beast’s name, GeneXpert-IV. The customs agent typed it in his search engine. He had an app for searching prices, very smart for getting an item’s value. But I knew, and the young agent soon found out, that no amount of searching would yield the actual price of the beast. Medical and scientific instruments that are this expensive do not have their prices listed on any web site. The young agent searched and searched and re-typed the name and searched again but he came up empty. Now the room was empty, too. The last passengers who had been selected for inspection had long since left. The young agent sighed. You can go, he finally said. I carefully re-fastened the latches on the shipping crate, pulled out the handle, thanked the customs agent and left the room. It was not until I exited the airport building into the hot sun that I realized that I had gone toe-to-toe with Haitian customs. I had stared them down and won.

     Outside in the reception area, I found my Christianville driver and we loaded the beast and my suitcase into the Land Cruiser. Danette was already waiting in the Land Cruiser (her flight had come in at about the same time as mine but my detour through customs delayed me almost 20 minutes). What’s in the big box, Danette asked. One of my instruments for the STI surveillance project, I said. In reality, it was a small victory and a big step forward in actually getting the project underway. Welcome to Haiti, beast!