Thursday, August 7, 2014



­­­­­­Haiti Dental Aid Trip
 July 12 to July 26  2014

     This narrative covers the second dental aid visit to Haiti of the group For World Wide Smiles in July 2014.  The first chronicle of June 24, 2013 contains general background and history of Haiti that will not be repeated here.  The previous trip was spent near the center of the biggest city, Port Au Prince which differs greatly from the more rural areas we worked in on this trip.  For a capsule history of Haiti and details of the previous trip read the 7/10 /2013 blog at http://jeffreymbernhardt.blogspot.com/.

http://www.nationsonline.org/oneworld/map/haiti_map.htm
Our Dental Aid Mission took place in the towns of Port Salut and Port-a-Piment in the lower left bottom third of the map.

Haiti's place in the Caribbean Sea
http://www.aschoonerofscience.com/wp-content/uploads/caribean_map.jpg

          We arrived in Haiti the morning of July 13 at 9:30 am local time.  There were several planes that landed around the same time as we did, and it was no surprise that there were only six immigration kiosks to handle what seemed like a thousand people.  It took us 2 ½ hours to move through the line to a frazzled immigration officer.  We were being picked up by our hosts at the airport and didn’t know where they were going to take us.  Thus we were unable to fill out a local address on the immigration form and the immigration officer at the kiosk couldn’t stamp our entry papers.  
A hillside community in the outskirts of Port Au Prince
     With a wave of his hand in a vague direction the immigration officer directed us to the “immigration office” which we were unable to find.  We entered the first office we could find surprising its denizen who was obviously not an immigration officer. The language we had in common were hand gestures and jumping up and down waving our passports and entry forms.   This was adequate to be escorted to a well hidden office behind two successive doors that was the administrative office for the immigration service.
      In that office there was a cacophony of ink stamps being pounded on piles of documents by four people.  It took a few minutes for the person who was obviously the boss to look up from his frenzied stamping.  We explained to him that we were being picked up and taken to a hotel or parish by a Catholic priest.  After the second time he asked us which hotel, it became clear that he just wanted something to put down on the form and couldn’t care less if it was accurate or not.  So we told him it was the closest hotel to the airport which was the hotel we stayed in the last time we visited.
Street Scene in Port Salut.  Note the three people riding the
motorcycle entering the picture, a common sight in Haiti.  What
is unusual in this picture are the riders wearing helmets -
something not usually seen in Haiti.



     Satisfied, he wrote down an address on all the forms and his stamp moving in a blur stamped all the forms and our passports.  Without looking up he handed back our passports and exit documents.  No sooner had I had closed my hand around them he was back to stamping more papers on his table.  In retrospect, we could have skipped the whole immigration line and walked into the office and no one would be the wiser. 
 
     The country is very densely populated in all the areas we traveled. In the course of a five hour drive from Port Au Prince to Port Salut, we saw crowds of people walking in the streets continuously except for only a few minutes of the drive.  It is hard to imagine how this many people living so densely can earn a living in a country with so few exports or external markets.  Compared to Central American countries we have visited agriculture is conspicuous by its absence.

Sherwin and Faria Shinn and  our Haitian host negotiating
our arrival arrangements for Port-a-Piment
     Our dental aid team this year consisted of Dr. Sherwin Shinn, dentist and founder of the the organization, For World Wide Smiles, Faria Shinn, his wife, Dr. Nannette Benedict, a dentist from Santa Cruz, CA., Sandy Harms, an executive administrative assistant and friend of the Shinn’s who also lives in the Seattle area, Jacob Bernhardt, Dr. Benedict’s and my son, Stacy Wall, a biology student at San Francisco State University, and myself, Jeff Bernhardt. During the second week at Port-a-Piment, we were joined by “Stami” Stamatoula Tsantes, a hygienist from Australia.
     We first traveled to Port-Salut and worked in a functioning clinic.  We were allowed to use their sterilization facility along with several rooms which had air conditioning. Within a few hours of starting to work more people than we could conceivably work on in several days had shown up.
The Port Salute clinic where we worked the first week


Sandy Harms and Jacob Bernhardt at the Port Salut Clinic.
A brief break in the hectic day of managing the delivery of
care.
     The first day at the Port-Salut clinic we had to choose the rooms we were going to work in.  We picked out a building separated from the rest that seemed ideal, but were told that this had been an isolation ward for cholera, and we might not want to work there.  The building was now unoccupied and it was never made clear to us how thoroughly it had been disinfected, or if there were plans to thoroughly disinfect it.  We agreed on two rooms at the edge of the clinic that had air conditioning and where the patients could wait outdoors in a shaded area.    
    
Our translator in Port Salut, Fleurigin Fenelon, Faria Shin, our host in the
country Father Webert Merilan, and Dominique Dorsainvil, 
who was instrumental in getting us permission to work in the
countryside and worked two grueling days as a translator. 
     The director of the Port Salut clinic did his medical education in Cuba, and was about to return to Cuba to study for a specialty. He had a private practice in the town of Port-Salut in addition to being the director of the clinic. Several of the Director’s staff were Cuban.
Dr. Nannette Benedict and Stacy Wall working
on a patient in Port Salut
      For us this was a pleasant surprise since we were able to communicate fairly well in Spanish, as opposed to French or Creole where we were helpless without an interpreter.  The Haitians who obtain their higher education in Cuba or the Dominican Republic are more likely to return to their country after completing their education than those who train in the US or Europe.
    We performed 522 procedures on 273 patients during our two weeks in Haiti.  Given the staggering need for care we certainly felt moments of disillusionment at the infinitesimal impact we made on the millions who have no access to any medical care, let alone dental care.  The inevitable breakdown of any method we have tried over the years to match the number of waiting patients to the number we can actually see inevitably leads to waiting patients who cannot be treated.  The latest addition to our team, "Stami" Stamatoula Tsantes, broke down and cried at the full bench of people we were forced to abandon at the end of our last day of the mission.  At the end of our allotted time, we had run out of most of our necessary supplies and could not continue our work under any circumstance. 
    An update on some of the measures of the country’s health since our first trip last year are as follows:  Unemployment which was stuck at about 70% since the earthquake has decreased painfully slowly to about 65%.  The government has financed the construction of many schools, and the percentage of children between the ages of 6 and 12 who are attending school have increased dramatically.   The government claim is that all children of eligible age are attending school but this seems to be an exaggeration. The higher education picture has not changed much, and most university degrees have to be obtained abroad.  The United States, Cuba and Dominican Republic were stated to be the most common university destinations.
Our group this year minus Dr. Shinn who took the picture.  From left to
right, Stacy Wall, Sandy Harms, Faria Shinn, Jacob Bernhardt,
Dr. Nannette Benedict, "Stami" Stamatoula Tsantes and Jeff Bernhardt
Photo by Dr. Sherwin Shinn
Dr. Shinn working on a patient in Port Salut

     We were in the capital only for a short time this year.  During the two hour drive out of the city we saw fewer tent cities, and fewer UN guard stations.  Some of the UN guard stations we passed had been converted to depots for various commodities.  One we passed was a depot for beer and soft drinks, but the UN logos and markings had not been removed. We have been told that the situation in the capital has improved both by American news media and by a wide range of our contacts in Haiti.  It has been unanimously reported that the crime rate has gone down and many schools have been built for education through high school.  Many governments and non-governmental agencies providing aid have become more sophisticated about seeing that their aid is not totally siphoned off into the pockets of corrupt middle men.
     The atmosphere in the countryside is a lot different than the atmosphere in the center of Port Au Prince.   Even though we saw continual crowds of people the duration of the drive into southwestern Haiti, the density of population in Port Au Prince is much greater than in the countryside.  There are streets in which literally a thousand people between every corner crowd both sides of the road for blocks. 
The south western part of the country is less crowded than the
Port Au Prince area but there are always people on the roads.
Haiti is one of the most densely populated and the poorest country in the western hemisphere.  Haiti's population is greater than 353 people per square kilometer with a total population of over 10.3 million.  (http://www.indexmundi.com/haiti/ and http://www.indexmundi.com/g/r.aspx?v=21000)  This does not include the 3 million Haitians residing in the Dominican Republic which will be expounded on below.  With between 65 and 70 percent unemployment a huge population wanders the streets in extreme poverty dependent on handouts for a meager existence.  In my conversations with Haitian priests working in Port Au Prince I was told that many people have migrated to the Port Au Prince expecting an improvement in their prospects.  Rumors of new industries hiring many people have traveled through the country and have been fostered by the government.  Desperate people who live in the rural areas where there are no new jobs continue to move to the city in search of work.
"Stami" Stamatoula Tsantes working on a patient
in Port-a-Piment

     Desperation has led people to attitudes and behavior that are extreme.  On the benign side, arriving at the airport the minute the new arrival steps outside one is accosted by many new friends who offer to give you special help getting a taxi, carrying luggage and any other of many services required to transit the fifty feet to the taxi stands.  Once you arrive at the taxi, your new friend will give you a hug and then demand twenty dollars American for their invaluable services.  Only the firmest refusal and even a carefully calibrated demonstration of anger will stop their persistent demands.
     This aggressive approach of demanding compensation for no useful service has obviously worked for some people in the past and is thus repeated.  It only has to work once in a week or two for a family to support itself for that time.  Once the showdown is finished and the outcome determined, (which in our case was no additional payment), in spite of high tension during the confrontation, incongruously are no hard feelings and everyone parts on civil terms.
   
Drive-by chicken sales
We have long experience with high pressure sales, bribery and begging in Mexico and Guatemala, but the tenor in Haiti is much different.  The level of desperation is greater, and the interactions last much longer than our experiences in other countries.  Few dealings end in success so the people are tenacious and start with exorbitant demands.     
     Our hosts were buying some live chickens to bring as a gift to a family who was having us to dinner.  There are vendors who have three or four live chickens they carry whose feet are tied with cord.  They dash up to the windows of passing cars slowed by the congestion of crowds and cars in the town.  The larger towns are quite busy and the roads jammed with people and vehicle traffic. It can take a half hour to get

Patient Before Treatment in Port Salut Clinic
Photo by Sandy Harms

Patient After Treatment in Port Salut Clinic
Photo by Sandy Harms

Patient Before Treatment at Port Salut Clinic
Picture by Sandy Harms


Patient After Treatment at Port Salut Clinic
Picture by Sandy Harms
The operation room in the Port-a-Piment clinic.  There was a second room dedicated to equipment setup and repair and sterilization, and which had the only reliably working sink.


through town.  The negotiations for the chickens lasted about twenty minutes and two vendors ran
alongside the car for at least a half mile before agreeing on particular chickens and a price.  The money and the chickens were exchanged through the window as the car moved with the flow of traffic at about 5 miles per hour.  At one point before the sale was completed the negotiations got heated to the point that one of the passengers of the car hopped out to bargain and argue, and then both he and the vendor had to run to catch up with the car. 
Stacy Wall assisting Dr. Benedict in Port Salut


     Another time we needed five gallons of purified water for our work at the clinic in Port-Salut.  The cost of the water was a little under one dollar US in Haitian Gourdes.  When the water vendor was presented with a US dollar we were offered a 12 ounce bottle of water.  Our initial insistence that one dollar should buy five gallons was brushed aside with a shrug and the offer of the 12 ounce bottle repeated. When my son and I both emphatically pointed at the written price of 40 gourde (less than a dollar US) posted on the wall for five gallons, the merchant shrugged and pointed at a 5 gallon jug.  We gave her the dollar and she filled the five gallon jug.  At the end of the transaction everyone smiled.
     One of the members of our group went on a walk and passed a National Police Station.  There was a policeman sitting on the curb in front of the station and as our colleague walked by he politely said “bonjour” and smiled.  The police officer asked him to stop in English and asked him where he was from.  When he replied “America”, the officer nodded and commanded “I like your watch, give me your watch”.  Our team member was not easily intimidated and replied “no, it’s the only one I have, sorry but I can’t give it to you”.  The policeman hesitated, then nodded and said “okay, go on your way.”
     
Dr. Benedict pulling a tooth with Stacy Wall assisting
The biggest problem with these modes of behavior and expectation is that for the few times they are successful people will be encouraged to focus their abilities in honing these techniques to extract resources from visitors. This will be at the expense of focusing their efforts to produce more lasting income by producing something of real value.
     For instance, the art of Haiti is of great esthetic and creative value but essentially has no means to market.  When one drives down the street it is common to see a variety of art in a range of media such as oil paintings, metal sculptures,  painted sheet metal hammered and cut into different shapes, all kind of craft boxes, jewelry and other more unconventional mediums.  It is hard to imagine who is buying the art
Jacob Bernhardt and Jeff Bernhardt recording equipment
shortages and documenting equipment failures to report
to manufacturers who have little experience with their
equipment in this kind of environment.
as most of the time we have seen these stalls there is no one around but other Haitians going about their daily routines.
Dr. Shinn and Faria Shinn finishing a restoration
    A shameful percentage of food is imported into the country.  The climate and soils of Haiti allow for a wide range of agriculture, and for many type of plants that would be hard to grow in most other places.  The availability of so much fresh water on the island is another remarkably fortuitous occurrence which is not taken advantage of for inexplicable reasons.  After the earthquake, much of the effected population would spend 30% of their waking hours searching for water.  The rural area was not effected by the earthquake, but the aftermath including cholera had a large impact.  The agricultural output of the country seems a tiny fraction of what it could be.
         The desperation of the populace has led to a high crime rate.  Many areas of Port Au Prince are too dangerous to visit.  There were many areas where it was too dangerous to venture without armed guards and areas that even the UN used to only go in force.  Last year we ventured no further on foot from our hotel than the UN guard tower could view easily.

Roadside repair in progress.  Vehicles are generally repaired
where they break down.  Most mechanics go to the site of the
breakdown.
     Haiti has mainly recovered from one of the largest cholera epidemics in history.  However the conditions that led to the outbreak have not been remedied and another epidemic could occur at any time.  It is thought that the epidemic originated from Nepalese UN peacekeepers in October 2010 who contaminated a river with untreated infectious sewage.  Prior to that cholera had not been seen in Haiti.  The severe lack of basic sanitation throughout Haiti was made even worse after the earthquake.  This resulted in the explosive spread of the disease.  Over 750,000 people caught the disease and over 8,500 died. (Pan American Health Organization,  http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=24597&Itemid= , New York Times, http://www.nytimes.com/2014/04/20/world/americas/un-struggles-to-stem-haiti-cholera-epidemic.html?_r=0)
    
Edgard Bommier translating for Dr. Shinn and Faria Shinn in
Port-a-Piment.
We prepared before we left for Haiti by educating ourselves on the symptoms and carrying the appropriate antibiotics with us.  As it turned out, the areas we visited experienced only a few cases in the last three months.  However, the cholera treatment and isolation wards remained ready even though there were no current cases at either clinic we worked at.  Infection control at clinics is a particular problem in a country with poor or nonexistent sanitation.  Fire is the first line tool.  In addition to the treatment and isolation wards, the hospital at Port-a-Piment had installed an effective incinerator which was used regularly.  The clinic at Port Salut piled its operating waste in a pit which was set on fire once a day.  There was a mattress, presumably from the cholera ward that had been burned and the remaining springs and other non combustible remnants pushed to the side of the pit.

Medical waste pit at the Port Salut clinic which was set afire
every day.  All manner of plastics, cans, and medical disposables packaging
was piled into the pit every day.  At the lower left the remains of a mattress
can be seen.  This site borders the ocean and aside from the pit itself could appear as a tantalizing
destination on any travel poster.
The incinerator at Port-a-Piment.  Medical waste was burned at least once every day.
The incinerator was installed by an NGO aid group.

The incinerator in operation.  We could smell the burning waste which included plastics, gloves, packaging and even used syringes anywhere within a quarter mile of the clinic.  That said, the incinerator is the most effective means available of mitigating the danger of infectious waste.
        
One of our dentists, Nannette Benedict was unfortunate enough to have a sink she barely touched fall off the wall, shatter, and a large chunk slice a two and a half inch gash in her leg.  We rushed to the hospital where we were to be working the next morning at shortly after 10pm the night before.


The cholera treatment and isolation ward at the Port Salut clinic

The cholera treatment and isolation ward at the Port-a-Piment clinic

The sign on the cholera isolation ward at the Port-a-Piment clinic
           We got to experience a sample of the medical care system of Haiti ourselves.  Within 10 minutes of arriving she was being attended by a physician.  The physician was competent, efficient and compassionate.  He was amply assisted by three additional personnel.     Within an hour Nannette had seven stitches, antibiotics and complete instructions as to care and  followup.  The stitching had required several injections of anesthetic and as anyone who has undergone this knows the injections are more painful than anything done subsequently.  She refused any pain medication for the remainder of the night as we were to work first thing the in morning.  The physician was impressed with her stoic behavior.  This was indeed an interesting way to start our week at the clinic.
     When the doctor started to work on Nannette our son Jacob saw that the lighting in the operatory was inadequate.  He retrieved a headlamp from our stocks and carefully placed it on the physician's head and turned it on while the physician was cleaning the wound and applying betadine solution preparatory to the anesthetic injection and stitching.  The physician broadly smiled and nodded his thanks.  We left him the headlamp and some spare batteries when we finished our work at the clinic.  
The seven stitches that Dr. Nannette Benedict received after
an injury sustained from a falling sink.
     The facilities were clean, and the disposables were sealed and in sufficient supply.  The staff acted efficiently and competently. Most remarkably to our cultural orientation was the lack of any required paperwork.  All the right questions were asked such as allergies to antibiotics, but since there
was no insurance or payment required, all staff were involved in the delivery of care.
     Although medical care is in extremely short supply for the populous of Haiti, what care there is seemed to be delivered efficiently and in a professional manner. 
Dr. Ronald Charles who stitched Dr. Nannette Benedict's leg after
she was cut by a falling sink.  Dr. Charles had never seen a dentist
before our visit.
          The physician on duty, Ronald Charles, was a  resident who was living at the hospital and was immediately available for an emergency. He was supervised by the chief of staff, a plastic surgeon who inspected much of his work.  He received commendations on his stitching of Nannette’s wound from his supervisor the next day.  Dr. Charles was educated at a medical school in the Dominican Republic.  As noted before, many Haitian professionals are educated in the Dominican Republic and Cuba.  He had just completed his rounds the year before and his work at the clinic was his residency.     
     The physician stopped in at our clinic that next morning to check up on Nannette, and probably out of some curiosity who this stoic woman was (he had expressed his surprise the night before on her remaining absolutely still while he worked on injections, debriding and stitching) and if she was really a dentist. He had never been to a dentist before.  Their roles were subsequently reversed as he had his mouth examined.
Dr. Nannette Benedict and Stacy Wall performing one of many
extractions
      The first facility we worked in was powered by a diesel generator and our presence there caused financial hardship. At the first clinic in Port Salut, the government had committed to paying for six hours a day of fuel and no more.  The list of people to be seen constantly increased as many people added friends and relatives to the rolls. We were not told about the situation with fuel for the generator and worked late every day. Although we were at first offended that we were asked for additional money for the overtime, it was made clear that the fuel costs were a real hardship for the clinic. 
The solar electricity generation panels at the Port-a-Piment
Hospital
At the first clinic we performed 229 procedures, sealants, fillings, extractions, cleanings, and debridements.
Colorful buses.  The bus in the foreground has a soccer theme.
The bus in behind it has a religious theme.
     The second clinic we worked at had a 12,000 watt solar generation system with battery backup.  It was provided by a variety of aid agencies and easily covered the clinic’s electrical needs since they had no air conditioning.  There we were able to work as late as we wanted and as our work wasn’t causing any financial hardship.   We and other medical aid groups who worked there were appreciated by the staff as well as the patients. 
Our translator extraordinaire, Edgard Bommier, in
Port-a-Piment
The availability of electricity without cost resulted in enthusiasm and cooperation of the hospital staff. This is a good example of appropriate and constructive aid with long term beneficial consequences.  Aside from the installed solar generation base Haiti imports all of it energy needs at great cost except for charcoal.  There is easily enough sun to supply Haiti’s entire populace with power, but the most recent statistics that I was able to find, only around 30% of Haitians had access to electricity.  Even without storage if decentralized solar and wave generators were put in place many areas would be electrified that now have no electricity.
     In Port-a-Piment our group split up and stayed in different facilities.  Four of us stayed at the clinic, and the other four stayed in the town of Port-a-Piment at the home of the Catholic priests who sponsored us.
The inverters, battery chargers, breaker and other control
circuitry for the solar electrical generation system at the
clinic in Port-a-Piment
     The priest's childhood home had no electricity or running water.  The home was set up for running water and electricity, in that there were electrical outlets, sinks and flushing toilets, but water and electricity had never been installed.  The toilets were flushed with buckets of water collected during the day. Showering and bathing was performed by pouring water from the buckets over us with smaller handled pitchers provided for this purpose.  One house in the block had a well, and the neighbors were considerate in only gathering water from the neighbors home during the daytime.  As a result, when a large number of guests were present which happened frequently, the water ran out before morning and the toilets could not be operated.   
 
Our sleeping quarters in Port-a-Piment











     The climate was very hot and humid.  Paradoxically, the temperature actually rose at night, reaching into the nineties Fahrenheit with 100% humidity.  We had to sleep in mosquito tents as there were several kinds of mosquitoes that frequented the night.  We were concerned about malaria, but it seems that the most
Stacy Wall set up a very direct method of communicating with
our patients.  We could just point to the appropriate sign on the wall
in English and Creole which had the most used statements and
questions we would need to say or ask.
common mosquito present at night was not a carrier.  Here is where simple fans could make life much more pleasant.  A simple breeze would have made the night temperature bearable, and the mosquitoes are not strong fliers and would be unable to frequent areas with fans.
     As it was, the air at night was commonly absolutely still, especially in the prelude to the frequent rain storms.  The onset of a storm would be accompanied by a slight breeze, and more spectacularly numerous lightening strikes and thunder coming from many directions.  I found it impossible to sleep
One of a myriad of colorful insects
in the humid heat, and got up and wandered around in the night.  The sounds of the night were fascinating and many times difficult to understand what was making them.  One night a beautiful pure tonal bird call was followed by the snarling of a dog.  As if the dog had attacked the bird the snarling cut off suddenly.  There was a moment of silence followed by the pained yelping of the dog.  Whatever had made the original pure tonal call turned out to be more than a match for the dog.  Other night sounds included braying donkeys, grunting pigs, roosters calling all night, the running of a few loud generators, fighting cats, various insects and cars passing through the town honking their horns.  The last was particularly baffling as we could not figure out why every car passing through the town after midnight would honk their horn continuously until they passed the town limits.             
Battery backup for the solar electrical generation
system at the clinic in Port-a-Piment
       On our second day at the second clinic another team member joined us.  "Stami" Stamatoula Tsantes is a hygienist from Australia who had learned about Dr. Shinn’s organization from her uncle who attended the last ADA meeting in New Orleans.  Dr. Shinn came to her uncle's attention as he  was awarded the Humanitarian of the Year award.  Stami's presence increased the number of patients we could see significantly.
The staff quarters at the clinic at Port-a-Piment.  Two members
of our team stayed in this facility.












     We saw 147 patients in Port Au Piment, and performed 293 procedures.  At this site we saw fewer hospital staff and we had a translator committed to helping us who shared our purpose.  The translator in Port-a-Piment displayed an idealism and dedication to
Edgard Bommier interpreting for Stami during a dental hygiene
session
improving the conditions in Haiti that inspired us.  He was a physical therapist by training, and on the hospital staff, but took time off from his regular work in order to assist us.  His command of English was excellent, and he had been educated in a special program that had been sponsored by Loma Linda University who had set up a satellite facility in Port-Au-Prince in order to train medical personnel.



 

 

 

Health Department Posters Displayed in the Port-a-Piment Clinic



We were not aware the elephantiasis was endemic in Haiti until we saw
this health department poster. 

This viral disease, Chikungunya, transmitted by mosquitoes has spread
to the United States.  Unlike Malaria, many of the local
people in Port-a-Piment reported contracting this disease.  The
disease is spread by the same mosquitoes that carry Dengue
Fever and these mosquitoes bite in the daytime.
  
Common family transportation throughout the country.

While we met many idealistic and honest brokers trying the help the less fortunate, the general level of corruption is high and taken for granted.  This level of blatant exploitation and self interest is frustratingly universal especially among the elite who could be instrumental in leading their country out of the morass it is in.  However, if we are honest with ourselves we have to admit that American CEO's would act similarly in these circumstances .  We see in the United States identical narrow focus on protecting one's self interest and the interests of the corporation one is in charge of.   This is routine with no thought of the impact to the larger society.  The difference is in an affluent society the impact on the masses of people is not as obvious or extreme and many times it is good marketing to act ethically.  Furthermore, in Haiti the biggest business is foreign aid and marketing the poor to attract aid is the largest single portion of the Haitian GNP.  This does not only involve Haitians, but a larger number of foreign partners and businesses.  See my previous blog at http://jeffreymbernhardt.blogspot.com/ 
 
Inside the cave at Port-a-Piment.  There are almost three
kilometers of chambers in this cave.
Haiti has many areas of incredible beauty.  Many of the beaches we saw were as beautiful as any we had seen anywhere we had traveled.  There are many surprising sights that could attract tourists from around the world.  The first day we arrived in Port-a-Piment we got to tour a cave that was remarkable.  The entrance to the caves is in a rain forest which makes it even more spectacular.  There are many caves in Haiti, and they are being explored and studied by personnel from several universities in the United States.  The cave in Port-a-Piment is developing the infrastructure to support tourism, including a parking area and a nature center.  Construction of both is just beginning.  There is a web page for the caves http://www.cavesofhaiti.org/haiti-cave-visit.html#caves .   Many of the other sites in Haiti are both remarkable and completely unexpected.  Haiti has the biggest fortress in the western hemisphere, Citadelle Laferrière, located in the far north of the country. It took 20,000 workers over a decade to build.  It was once armed with 365 cannons and many cannons still remain.  This and other remarkable natural and man-made wonders can be viewed at http://www.hougansydney.com/landmarks-of-haiti.php
    
A cave mouth at Port-a-Piment
There is a crisis brewing between the Dominican Republic and Haiti.  There are an estimated 3 million Haitians in the Dominican Republic who moved there to find work.  In general, they do work that the Dominicans won't do  such as harvesting sugar cane.  These workers have been there now for multiple generations and subsequent generations from those who originally entered the Dominican Republic have no Haitian identity papers nor are they citizens of the Dominican Republic after a recent court decision.  Those born in the Dominican Republic many times speak only Spanish.  The Dominican Republic is threatening to deport them back to Haiti, even though culturally they are no longer Haitian.  Tensions between the two countries are rising and the good will between the two countries present right after the devastating earthquake in Haiti has faded quickly.  The history between Haiti and the Dominican Republic is sordid and complicated (See the Guardian,       http://www.theguardian.com/commentisfree/2013/oct/07/dominican-republic-haiti-long-history-conflict , All Empire Online History
 http://www.allempires.com/article/index.php?q=conflict_haiti_dominican ).  The difficulties in the past between the two countries  certainly color the interactions of today.
 
      
Cell and relay towers outside Port-Au-Prince.  We found few
locations where there wasn't cell service and we rarely
experienced dropped calls.
This acknowledged,
Haiti is plotting a sophisticated political course in relations with Cuba, Venezuela, the United States, and the Dominican Republic to mention a few countries who don't always see eye to eye.  We met doctors educated in Cuban medical schools and Cubans who had made their home in Haiti.  The days where the excesses of a brutal dictatorship would be completely ignored if  they professed opposition to the designated enemies of the United States seems gone forever.  Repression, corruption and exploitation have had to adopt a degree of subtlety.
Dr. Shinn and Faria Shinn evaluating a patient at the close of a
long work day
     Haiti’s government has been nothing like the horror show of Papa Doc and Baby Doc for many years and the support of foreign nations for such dictatorships in the name of opposing communism is no longer viable.
     The overriding question is can this country advance beyond a poverty stricken nation with the majority of its populace unemployed, uneducated past primary school, the worst health status in the hemisphere and foreign aid as more than half its GNP?  Are they in an irreversible downward spiral, or as tragic, a static state from which there is no possible escape?  The sight of endless miles of milling crowds of people in the street as we drove through Port Au Prince for two hours does not serve the forces of optimism.  The level of corruption and inefficiency visited on the country from inside and outside does not bode well for the herculean efforts required to surmount the colossal obstacles to improvement.
     This is not a just a test for Haiti, but for the whole of humankind; a measure of the prospects of the future of civilization. Technology and the interconnectedness in the 21st century insure that the consequences of the poisons of suffering and deprivation seep widely and contaminate even the most isolated enclaves of wealth and privilege. The corruption and greed that has accompanied the world’s efforts in aiding Haiti reflect not so much the situation in Haiti but the ability of the industrialized nations to function adequately within the boundaries of their own efforts at democracy.