During one of Dr. John May's recent visits to the National Penitentiary here, a gaunt prisoner pulled out a photo of himself taken two years earlier when he was muscular and healthy, holding his toddler son in strong arms.
"Before and after," May summed up the photo and the man later, when he had confirmed that the prisoner has AIDS.
A 90-minute airplane ride had brought May from South Florida to Haiti, where infectious diseases incubate in the prison among men crowded so close that some are forced to stand day and night.
AIDS and tuberculosis go undiagnosed and untreated here, develop resistance to medicine and spread, killing some inmates while giving others a contagious keepsake to take with them when they get out.
HIV infection rates in prisons can run at least three to 10 times higher than rates among surrounding populations, but no one in this prison keeps track of how many have the virus.
These are some of the reasons May, an American correctional facilities doctor, started coming here in 2001 and keeps coming back, bringing care, medicine and supplies.
"You have to pay attention to jails and prisons," he says, "because that's where the disease is."
Experience has taught May that getting people to care about what happens in other countries is hard.
"Getting people to care about what happens inside prisons is even harder," he adds.
More than a dozen years after U.S. officials were alerted to overcrowding in this prison, it is more crowded than ever, with rivers of human waste running outside cells caging ten times more men than they were built to hold.
And while $55 million in U.S. money flowed into agencies and organizations in Haiti last year alone as part of the President's Emergency Plan For AIDS Relief, none of it flowed here.
Prisoners came from, can return to U.S.
When May, inspired by a presentation on prison conditions during an international AIDS conference, visited Haiti's National Penitentiary in 2001, he found the place overcrowded to crisis proportions with 1,500 men inside.
"It was a desperate, desperate place," he said.
An overwhelmed and underpaid staff struggled to meet patients' needs without adequate supplies of medicine and with no full-time doctor. Prisoners with infectious diseases, untreated, mingled with others. With meals consisting of broth, malnutrition killed some, left others with lasting damage.
Haiti does not allow bail, so many of these prisoners, charged with misdemeanors, were waiting months, even years for their cases to be heard in a chaotic court system.
All the same, most of the people in this prison, May points out, will eventually get out one way or another. Rioting in 2004 emptied the prison of all 1,500 inmates that it held then, and in escapes since, from a dozen to 600 prisoners at a time have disappeared into the general population. Many of the prisoners have tattoos, indicating they have lived in the United States, where that form of self adornment is much more common, and where they are likely to return.
May's mild demeanor belies a willingness to pursue a task into unspeakable squalor, so he returned with other volunteers not just to that prison but to ones in the Dominican Republic, Jamaica, Tanzania. Two years ago, he founded Health Through Walls, a nonprofit organization.
May describes "gentle progress" over the years he has come here, saving lives one at a time, stocking a pharmacy, installing tuberculosis-testing equipment as well as a fan and sink, fighting epidemics of malnutrition and scabies.
Still, HIV continues to spread by consensual and forced sexual encounters in these densely crowded cells as well as by needle and razor sharing. The weakened immunity of HIV-infected prisoners speeds the spread of tuberculosis.
When during a visit last spring, four prisoners were brought to May with legs swollen from standing because they had no place to sit or lie down, he said, he had to do more.
May, who also is medical director for the Miami-based Armor Correctional, brings surplus medicine and supplies as well as hundreds of bars of soap on the trips he makes at least bimonthly to this and other prisons. Sometimes he is joined by other physicians who come as volunteers including Palm Beach County Jail Medical Director Dr. Pierre Dorsainvil, who serves on the board of Health Through Walls.
In visits during recent months, though, May has brought more people — including former Armor colleague, now Florida Surgeon General Dr. Ana Viamonte Ros, Haitian-born physician and entrepreneur Rudy Moise, and a former justice department staffer and court reform activist named Maurice Geiger.
Each time now, as he hands out soap in the cell blocks, May shows visitors the medieval conditions that result when 3,050 to 4,000 inmates are jammed behind the walls built to hold no more than 1,000.
Security concerns now dictate prisoners be "locked down" 23 hours a day. With no access to outside toilets, prisoners urinate through the bars and defecate into plastic bags thrown into gutters outside suffocatingly hot cells. When the gutters are hosed and doused with cleaning fluid each morning, fumes of sewage and bleach fill the humid air.
Strips of cloth tied to window bars that look more like hammocks for dolls than for grown men serve as beds for some inmates. Other prisoners share windowsills, where they sleep with their legs pressed to their chests.
With floor space scarce, some pay money to sit or lie down. About 20 live wedged in a cage under a stairway with no room to stand.
Those are among the more fortunate.
The four prisoners with swollen legs he saw, May said, had been standing for two weeks.
Data on deaths scarce
May's list of needs at Haiti's National Penitentiary includes lab equipment, a full-time doctor, a consistent supply of medicine. Quiet spoken and direct, he avoids harsh words, and assembles his thoughts before speaking. He fell silent as he ended his list, before summing up its impact.
"The first priority is to deliver the care that's needed to those who are going to die unnecessarily," he said. "There are patients there who are going to die and who have died from conditions that are treatable."
Data on deaths, or even on the infectious illnesses that are tracked in the U.S. to protect public health, are hard to come by here. But last year, May documented conditions at the prison in a Health Through Walls application for PEPFAR help to address HIV in the prison. The application was turned down, and May is applying again this year.
In the meantime, May found a new ally to tackle conditions most basic to health in a Haitian-born long-time U.S. corrections staffer, Robinson Cadet, beginning a one-year stint as United Nations-sponsored consultant at the Port-au-Prince penitentiary.
"I see things here that make me want to cry," Cadet has said.
Cadet already had met May during training prior before coming to Haiti, and by the time he met him again, during one of May's weekend trips to the prison, Cadet had conceived an economical plan to clean the cell blocks by enlisting inmates in the effort.
A few weeks later, after the visit with May, Moise wrote a check for $25,000 to launch the plan in the worst cell block, known as "the Titanic."
Trial wait a death sentence
PEPFAR officials said recently they are aware of conditions at the penitentiary and believe nonprofit groups are addressing some of them. They could not name the groups though, and those at the prison have said no organization other than Health Through Walls — with May's visits — has had a presence there.
U.S. Ambassador to Haiti Janet Sanderson also said recently that the United States is assisting with court reform efforts, to shorten the time arrestees spend here awaiting trial.
Past such efforts have not gone far, though.
In 1994, the United States Agency for International Aid, which now oversees PEPFAR money, undertook a billion-dollar reform of the Haitian court system by giving the money to a contractor, which in turn hired a disbarred attorney with a record of felonies to run the program.
Former Justice Department staffer Geiger was there then and walked 60 Minutes reporter Mike Wallace through the prison five years later, to show how little had changed.
When Geiger returned on a September trip with May, conditions had worsened exponentially.
A haggard and fevered prisoner lay on a mat in the infirmary, his heart racing. He had been found on a cell floor two weeks earlier, thanks only to a prison wide search for contraband. A skeletal and hollow-eyed 20-year-old prisoner sat on the floor in the next room, too weak to stand, and told Geiger that he was healthy when he was locked up two years earlier on suspicion of shoplifting.
Both men, Geiger held, had essentially received a death sentence without trial.
"It would be interesting to take a look at these cases and ask, 'To what end? To what end are you holding these people?'" Geiger said. "It can't be punishment, because they haven't been found guilty of anything."
First, do no harm
One standard for international health in prisons, May says, has been to make it equal to the care in the community surrounding the prisons.
"But in a place like Haiti, what do you do if what the community can access is not appropriate, not good, not enough?"
Instead, he says, the standard for health care in prisons should be to live up to the physician's creed: "Primo no nocere."
"It means, 'First do no harm.' When a person's incarcerated, harm should not come to them as a result of their confinement."
On a September trip, May brought antiretroviral drugs to the emaciated prisoner who two weeks earlier had pulled out the photo of his former healthy self.
The drugs have turned AIDS from a brutally deadly disease into a long-term, manageable condition since 1996 — for those lucky enough to get the medicine.
But the rationale for not making it available to patients such as this man, in prisons, in impoverished countries, in remote rural areas — in short where the most victims of the epidemic are found — has been that these are the people who won't maintain the regimen necessary to keep from becoming drug-resistant. "Of course, sustainability is essential," May says, "but so is access."
Hope is trickling in, he said, with word that USAID recently pledged $2.7 million to address prison conditions in Haiti, with $200,000 to address health and sanitation at the National Penitentiary.
In the meantime, he is continuing on his own.
"If the systems aren't going to come together," he said, "I need to treat this patient in front of me."