THOMONDE, Haiti — ­­­While Nehemie Philippe, the assistant mayor here, describes the obstacles her community faces, the hum of the town's only generator dulls the sound of the rain on the rooftops nearby. The generator was donated by Project Medishare, a U.S. nonprofit group that is dedicated to establishing an effective health care system in Haiti.

Medishare is one of many U.S. organizations working on improving the health of this community, where between 5 and 10 percent of the population is infected with HIV. Although there are no easy answers, local organizations are looking for solutions to the health crisis.

Thomonde and its surrounding villages are home to about 35,000 people in the Central Plateau, one of the poorest areas in the poorest country in the Western Hemisphere. Many in the region try to get food by whatever means possible. Farmers say they wish they had longer seasons to grow more crops.

The department of the Central Plateau has one of the highest rates of malnutrition in the country — despite the fact that its residents are primarily farmers. The hills and mountains are denuded of trees to make charcoal, which causes high rates of topsoil loss when rains come to the island. As a result, the land, which is exhausted from deforestation and desperate slash-and-burn farming techniques, must be burned more frequently and is becoming more difficult to farm.

About 92 percent of children here under 5 suffer from some degree of malnutrition. Philippe says malnutrition is the primary cause of the residents' poor health.

A survey measuring how many people live in hunger or with the fear of not having enough food to eat was conducted in 2005 in Boucan Carré, another impoverished town in the Central Plateau. The responses showed that the day before the survey, 9 percent of children had gone without food.

Malnutrition contributes to the spread of HIV, experts say. As with many other diseases, the populations that are least able to shoulder the brunt of the epidemic are the ones that are most seriously affected. Public health studies continue to show that poor communities around the world lack the health care infrastructure to handle the burden of disease.

Frank St. Brun, a health agent with Project Medishare in the Central Plateau, is the father of nine children and the husband of two women. He became involved with Medishare initially as a volunteer for a vaccination campaign. He tells the story of two sisters from his area. Their parents were unable to care for them. The girls moved to Port-au-Prince, the capital, and it was there that they contracted HIV — probably, St. Brun says, through sex for food or money. They have returned home and are now receiving medication. "They are 14 and 15 now."

In the Central Plateau and throughout Haiti, economics often force a woman's hand. Dr. Maxi Raymonville, a doctor with Zanmi Lasante (Creole for Partners in Health) in the Central Plateau region, says that women often seek additional partners to support themselves and their families. "They are really poor, and when a woman here has a child from a man, and after some … years this man is gone and now there is the survival, no one to help with this child. And this woman has to get another partner and that's the situation we see to put this woman at risk to contract HIV. … The only reason for that is the social condition."

The U.S. State Department's Office of Global AIDS Coordinator, which administers the funds for PEPFAR (the President's Emergency Plan for AIDS Relief), issued a report in May 2006 recognizing the complex interrelationship between HIV and an unstable food supply.

Farming in Thomonde

Tony Guerrier, a Thomonde farmer, says that farming is something he loves to do, but in the Central Plateau, there isn't enough water to irrigate his land.

one of the main roads in the central Plateau town of Thomonde

He greets visitors on a cement patio under a shady tree just in front of his house. Two teenage daughters sit on a bench braiding each other's hair, and red fish swim in a small pond nearby. The fact that his house is made of cement shows that Guerrier's family is better off than some, but he is still concerned about his ability to continue farming.

Guerrier says the crops he grows depend on the season. Currently, he is growing plantains, but they haven't fruited because he couldn't irrigate them. In the dry season, he grows hot peppers and sometimes corn. Because he didn't have any water this past year he could grow food only for his family, none to sell.

He wakes up at 5:30 in the morning and walks or rides his mule 20 minutes to get to his land. His wife works with him, as do their seven children when they aren't in school.

In addition to what he grows, he buys peas, oil and rice from the market. If he could, he would farm more. He would farm tomatoes, cabbage, manioc, corn and tobacco if he could.

Guerrier says the rains used to start in March, but now they start in April, and so that's when his farming starts. He farms only until June, when the rains stop. It may also rain at times during hurricane season in August or September, but there isn't enough rain to allow him to farm as long as he'd like. Guerrier says he would like to have the money to buy a water pump so he could irrigate his fields and feed his family greens throughout the year.

Project Medishare

Project Medishare is establishing roots here. With mobile clinics, construction underway for a 40-bed hospital, and a 10-year history of cooperation with the community, including traditional healers, Haitian governmental officials, local nonprofits, faith-based and community-based organizations, Medishare has earned respect from the local community for its work.

Project Medishare also plans to apply for PEPFAR funding for a nutrition project called AK Mille, also known as AK-1000.

AK-1000 is a highly nutritious powder made from locally grown rice, corn, millet, wheat, and beans that is used to make porridge. It was invented several decades ago and is promoted by a number of nongovernmental organizations (NGO) in Haiti.

Medishare believes that its program is different, because it will target nutritionally deficient HIV-positive individuals who are receiving treatment, while production of the powder will help boost the local economy.

Medishare intends to fund a local factory that would partially precook the powder so that families wouldn't have to use much firewood to finish cooking it.

Ellen Powers, the group's executive director, said the AK-1000 project will combat malnutrition in the HIV population as well as in pregnant women and patients with tuberculosis. The program will also help the community's economy by purchasing the grain locally, providing employment opportunities to vendors in the marketplace and local farmers.

Obstacles

Powers recognizes, however, the many obstacles a nutrition project may face. Already, there has been tension between Medishare and another aid organization in the Thomonde region, which in addition to having a high malnutrition rate has a high fertility rate (7.6 children per mother).

These houses sit on the national road from Port-au-Prince to Mirebalais. Through a program funded through the U.S. Agency for International Development, the other organization, World Vision, provides American-grown and processed food to malnourished children and to pregnant and lactating women.

Medishare originally viewed the World Vision program as encouraging women to have more children in order to gain access to the food. "That's where we had a huge problem," Powers said, "because here we are trying to decrease the fertility rate and meanwhile… World Vision is giving out free food to pregnant women."

In addition, the food World Vision distributes is imported and therefore not benefiting the local economy. It took a couple of years to get World Vision to the table with Medishare to discuss the needs of the community.

Powers also criticized some foreign aid organizations that she said don't interact with the Haitian government. "I think some of the smaller NGOs are making mistakes," she said. "They look at the government and they say it's corrupt, so I'll do my own thing. [This is] without understanding that there's a national plan, whether it be in education, health care, or agriculture. Have some respect for the country."

Andreas Deuble, the HIV/AIDS specialist on the Haiti World Food Programme staff, identified another concern with targeting food programs to HIV patients. In a country where only a small percentage of those who are eligible for antiretroviral treatment drugs for HIV are receiving them, how, he asks, can an organization deny food to those who are already suffering by not getting treatment? Is that not a form of double punishment? "We need to see what is ethical and not only what is a medical question," he said.

But Powers explained that this is where Medishare's project can play a role. Rather than distributing food, it can serve the wider community through employment opportunities, so that a farmer like Guerrier might be able to afford the water pump he so desperately wants. And with that pump, he would have a longer farming season and could provide more nutritious food for his family.