VIVIENDO CON VIH: LA EXPERIENCIA PERSONAL DEL ESTIGMA

 

Migratory routes from Haiti to the Dominican Republic: implications for the epidemic and the human rights of people living with HIV/AIDS

 

Rutas migratorias desde Haití a la República Dominicana: implicaciones para el estigma relacionado al SIDA y los derechos humanos de las personas inmigrantes infectadas

 

 

Irene López-Severino^1,2; Antonio de Moya

 

 

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ABSTRACT

The presented study analyzes the possibility of a relationship between the migratory flow from Haiti toward the Dominican Republic and the spread of HIV/AIDS, as well as implications for the human rights of immigrants living with the infection. Its purpose is to identify possible areas of intervention and research in order to increase the participation of this population and its organizations in HIV/AIDS awareness and prevention efforts. The current study was carried out in three main phases: 1) review of existing documentation on the relationship between Haitian immigration, HIV/AIDS, and the human rights of infected people; 2) semi-structured interviews with key informants, authorities, and experts in the areas of concern; and, 3) eight case studies of Haitian immigrants living with HIV/AIDS in agricultural bateyes in the Dominican Republic. Results evidence the stigmatizing scenarios that immigrants living with HIV/AIDS face.

Keywords: Acquired Immune Deficiency Syndrome, Stigma, Migration, Haiti, Dominican Republic.

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RESUMEN

En el estudio aquí presentado se analiza la posibilidad de una relación entre la migración de Haití a la República Dominicana y la propagación del VIH/SIDA, a la misma vez que se exploran las implicaciones a los derechos humanos de los emigrantes que viven con el virus. Su propósito es identificar áreas de intervención e investigación para aumentar la participación de esta población y su organización en asuntos relacionados al VIH y su prevención. El presente estudio fue hecho en tres fases que incluyeron: 1) revisión de documentos existentes sobre la relación entre la migración Haitiana, el VIH/SIDA, y los derechos humanos de las personas infectadas; 2) entrevistas semi-estructuradas con informantes clave, autoridades, y expertos en el área; y 3) ocho estudios de caso de emigrantes haitianos que viven con VIH/SIDA en bateyes en la República Dominicana. Los resultados reflejan los escenarios estigmatizantes que enfrentan las personas emigrantes que viven con VIH/SIDA.

Palabras clave: Síndrome de Inmunodeficiencia Adquirida, Estigma, Migración, Haití, República Dominicana.

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This investigation was part of a multicentric study on the human rights of people living with HIV/AIDS, carried out simultaneously in Argentina, Ecuador, Mexico, the Dominican Republic, and Venezuela by the focal points of the Latin American and Caribbean Council of AIDS Services Organizations (LACCASO) in those countries for the Joint United Nations Program for HIV/AIDS (UNAIDS). This project should be seen as the exploratory stage of a broader study that must be made of this long standing and complex problem between two nations, a problem that must be redefined in light of recent events relating to the HIV/AIDS pandemic. Its goal is to provide new and culturally appropriate alternatives in response to the challenge that this disease presents, not only to the population of the entire island, but also to its diaspora in the Caribbean, North America, and Europe.

The study that has been carried out analyzes the possibility of a relationship between the migratory flow from Haiti toward the Dominican Republic and the spread of HIV/AIDS, as well as implications for the human rights of immigrants living with the infection. Its purpose is to identify possible areas of intervention and research in order to increase the participation of this population and its organizations in HIV/AIDS awareness and prevention efforts. Due to time and budget constraints, we are currently unable to enter in detail into the important consideration of the human rights of uninfected Haitians and Dominican Haitians (known as Arrayanos³), in terms of their possibly coming under suspicion of being infected, i.e., of their being collectively stigmatized. It should be remembered that, at the onset of the epidemic in the U.S. in the 1980s, Haiti was already thought of as an "international pariah because of AIDS" (Chaze, 1983).

The main objectives of the study were to: 1) Gather and analyze existing documentation regarding the HIV/AIDS situation in Haiti and the Dominican bateyes (settlements of sugar cane workers) and the relationship of that situation to Haitian immigration and the human rights of Haitian immigrants living with HIV/AIDS in the Dominican Republic; 2) Obtain information from experts on the core issues regarding migratory routes and modalities, both traditional and recent; 3) Analyze the possible connection between migratory routes, including the relevant socioeconomic factors, and the spread of HIV among the immigrant and resident populations of Haitians, Arrayanos, and Dominicans; 4) Gather information on the management of the human rights of Haitian immigrants infected by HIV.

Migration and Health

The relationship between migration and emigrant health is one of the most controversial topics in international health, one that has inspired passionate discussions for centuries. Some researchers identified the main sources of problems relating to the health of immigrants in their countries of destination. Prominent among these are: 1) their socioeconomic status compared to the host population; 2) differences in worldviews concerning issues of health and disease; 3) educational difficulties and the lack of access to necessary resources; and 4) the impotence of medical personnel in the face of many diseases. Research of the migrants' views on their health problems reveals concrete barriers for obtaining medical attention, including but not limited to mistrust among health personnel, degenerative diseases, wandering from one service to another, and financial problems. In recent years a notion has gained ground that some of these problems may be resolved by seeking help from religious or traditional healers. In this study, perhaps for the first time in the Dominican Republic, the voices of Haitian immigrants and of those who live and work with them are heard, in an attempt to better comprehend from within their understanding of HIV/AIDS.

Immigrant Women and Children

There is little doubt that immigrant children and women are capable of understanding and learning a new culture and a new language, but there is a need to study in greater depth how this can be a function of the degree of marginalization from social contact with the host culture that many immigrant women may experience, particularly those who do not work outside the home.

Studies on migration classify women and children in terms of their general vulnerability, predominantly associated with the lack of command of the host country's language. Ford, King, Nerenberg and Rojo (2001) pinpoint three levels of risk among migrant women. The most marginal and vulnerable group consists of women who do not speak the language of the country of destination and children born in their mothers' country of origin. This group is followed by one consisting of women with a basic knowledge of the language and children born in the host country and who speak the language. The final group includes women who are native or who arrived at an early age and speak the language, and children of mixed unions who were raised speaking the host language.

The majority of the women in the world who are infected by HIV live in the poorest countries and communities, because poverty and gender inequalities increase women's risks. Farmer, Connors and Simmons (1996) state, for example, that serial monogamy is a common practice among poor Haitian women. "These are weak monogamous unions leading to the procreation of a child but generally lasting no more than a year. Once such unions are dissolved, the women are left with new dependents and an even greater need for reliable partners. The instability of these unions aggravates their financial situation and may place the woman at high risk of contracting HIV or other STDs" (Farmer et al., 1996). It is often the case that a woman, who has been infected, upon the death of a partner with AIDS and needing to quickly establish relations with another partner for reasons of survival, places the new spouse in a situation of high risk of acquiring the infection.

International Migration and HIV/AIDS: Recent Studies

Some recent studies on the relation between migration and the risk of acquisition and transmission of HIV in various societies emphasize the risk factors and the necessity of HIV counseling and the control of other STDs. Adrien et al. (1998), for example, found that unprotected sex during return trips of Haitians from Canada to Haiti may be a risk factor for HIV infection. In Zimbabwe, Gregson, Zhuwau, Anderson and Chandiwana (1998) report that the perception of personal risk among migrant men was quite high (42%) and was correlated to bachelorhood, exposure to the media, and contact with medical services. In Holland, Fennema (1998) found that more than three fourths of HIV positive heterosexuals of both sexes were foreigners. In Italy, Suligoi and Giuliani (1997) highlight the need to increase awareness of the spread of STD risk factors among immigrants. In the Russian Federation, Tichonova et al. (1997) confirm the finding that the transmissivity of HIV is increased by infection with STDs.

The Dominican Republic and Haiti: Historical Relations between the Two Countries

The island of Hispaniola is shared by two nations, politically organized as the Dominican Republic and Haiti. Along with Tierra del Fuego, Saint Martin, Ireland, and New Guinea, it is one of only five cases in the world of an island shared between two countries (Vega, 1988). The ethnic, cultural, political, and historical development of the two societies has been different yet intertwined since the seventeenth century, although their destinies might appear to be joined by their common geography and ecology. We Dominicans and Haitians are the children of slave owners and slaves. Our mothers were Taíno mestizas, our fathers were Caribes, Europeans, Africans, Asians, and Americans. Despite this vocation for diversity, or perhaps precisely because of it ("to be and not to be the other"), the Divided Island, today menaced by its regional HIV/AIDS subpandemic, has been an imperial borderline of racism in the Americas.

The Border between the Dominican Republic and Haiti

According to the historian Frank Moya-Pons (1998), the treaties of Aranjuez, Basilea, and Ryswick were signed by Spain and France in the seventeenth and eighteenth centuries, establishing the territorial boundaries of their respective colonies that shared the island of Hispaniola. In 1795 the Spanish part was ceded to France in consequence of the French (1789) and Haitian (1791) Revolutions. In 1794 Toussaint L'Ouverture occupied land that had formerly belonged to Spain. This occupation was never acknowledged by the authorities of the Spanish part, Santo Domingo, after the so-called War of Reconquest in 1809. In 1822 the Haitian government once again occupied the entire island, incorporating the former Spanish territory into Haiti. This action was again repudiated in 1844 when the new Dominican Republic was founded. The Dominicans continued to claim sovereignty over what they considered to be Haitian-occupied territories, and there was war between the two nations for a number of years. The year 1861 saw the Annexation by Spain of the Dominican territory. The War of Restoration, however, blocked that plan and achieved the Dominican Republic's separation from Spain, leaving the boundaries as they had been defined by the Haitian government between 1822 and 1844.

In 1867, the Dominican Republic signed the first Treaty of Peace, Friendship, Trade, and Navigation with Haiti. The two governments signed various treaties and agreements in 1874, 1880, 1884, 1895, 1899, and 1900. There were more talks in 1911, 1929 and 1935. At the 1935 meeting, the construction of an international highway was agreed upon; some sections of this highway were to mark the boundary line between the two countries.

The Dominican Sugar Industry: Sugarmills and Bateyes

According to the sixteenth-century Indian Chronicles, the term batey was used by the Island's aboriginal Taínos to designate the plazas where ceremonial ball games and other social and ceremonial activities took place. This word has been carried over into the Spanish language, principally to refer to the communities where the laborers from the sugar mills live with their families (Ramírez, 1992).

According to Cedeño (1993) there are two basic types of bateyes in the sugar industry: the central (headquarters) and the agricultural (outlying). The central batey is located very close to the factory; it is typically semi-urban or just urban. Its inhabitants are involved in the industrial labor of the actual grinding of the sugarcane and with the major portion of the administrative process over all the personnel and equipment for the agricultural and industrial areas of the sugar mill. The agricultural batey is a rural community; the majority of its population works at tasks related to planting, cutting, carrying, weighing, and transporting the sugarcane to the sugar mills.

One peculiarity of the agricultural bateyes is the ethnic composition of its inhabitants, which is greatly determined by the presence of immigrant labor, usually cheaper than native labor, primarily Haitians and their descendants. The sugar industry has used the importation of workers as a resource since the late nineteenth century, in order to keep wages low and reduce production costs (Ferrán, 1986). Starting with the final quarter of the nineteenth century, when the sugar industry began its ascendancy, dozens of sugar processing plants were founded. Many of these would later close, as the profitability of sugarcane production decreased during the final third of the twentieth century. Until the late 1980s, when two government-owned centrals were closed, the number of sugar mills remained steady at 16 (Ferrán, 1986).

It should be pointed out that the bateyes are not necessarily limited to the context of the sugar industry; rather, the term is being applied to marginal urban barrios when a Dominican Haitian and Haitian population is present. Moya-Pons (1999) indicates the manner in which the gradual occupation of land surrounding the old sugar mills has given form to important settlements.

A phenomenon worthy of study is the change in these growing towns from sugar-processing centers to cultural centers, where a community of migrants, instead of looking for work in a sugar industry, may perhaps come in search of a familial community where they will not meet with quite so much discrimination. (p. 25)

Legality and Illegality of the Haitian Immigrants

The clandestine and illegal manner in which Haitian immigrants arrive is the point of departure for the super exploitation of thousands of Haitians who work in the sugarcane plantations, the construction sector, and other local agricultural crops such as coffee, cacao, and rice. The Haitian often enters the country illegally and then, when the sugarcane harvest is over, stays illegally to work in other areas. Haitian immigrants are not protected by the Labor Code in effect in the Dominican Republic, nor by any other legal provision of any sort (Cedeño, 1993; Veras, 1986).

According to the Dominican Constitution, children of Haitian parents who are born on Dominican soil have the right to Dominican nationality in accordance with the principle of Jus soli; this contradicts the Haitian Constitution, which establishes that any child of a Haitian is Haitian, regardless of the place of birth, in accordance with the principle of Jus Sanguini. This discrepancy has generated conflicts surrounding double nationality or absence of nationality. Children of Haitian immigrant fathers and Dominican mothers grow up without any documentation whatsoever. Reliable sources report that for some time birth certificates have not been issued to any children of Haitian descent born in the territory, which causes repercussions for the child's education within the formal school system, since the schools require a birth certificate in order to register a student.

From 1940 until 1952, Haitian braceros worked illegally as a consequence of clandestine trafficking. In 1952 an agreement was reached under which Haitians could be hired in Haiti and enter the Dominican Republic as temporary workers. This agreement was passed in conjunction with a labor contract form to be signed by the company that would employ the bracero and by the worker himself. In 1959 and 1966 similar agreements were reached. There does not appear to be a consensus today as to whether these agreements are still in effect through automatic renewal or whether they have expired.

Anti-Haitianism

The anti-Haitianism of broad segments of the Dominican population is a complex phenomenon rooted in the ethnic and economic development of the parallel Spanish and French colonies on the island, in their historic struggles for independence, in the border disputes to define the two territories, and in the presumed economic pressures that generate immigration. According to Vega (1988), Dominican anti-Haitianism in the nineteenth century was based on "the Haitian objective of controlling the eastern part of the island". We must, however, deconstruct these attempts to localize the fault for anti-Haitianism on the acts of the Haitians themselves, i.e., blame the victims for their victimization.

It is important to point out that many of the central figures of Dominican national history are the creatures of their resistance to the Haitian occupation of the eastern part of the island in the nineteenth century. There is apparently an effort by the dominant classes to maintain the rejection of the "negritude" of the Haitian and defend the "Spanishness" of the Dominicans. This type of anti-Haitianism, which according to Vega (1988) is self-defined as a deliberate effort to place the "mestizaje [racial mixing of Europeans and indigenous peoples], Hispanism and Catholicism" of the Dominicans in direct opposition to the "Africanism and negritude" of the Haitians, also reflects the racial prejudice against even Dominican blacks that has existed since the colony was founded. Around the late 1930s, however, perhaps reflecting the Nazi policy of ethnic and racial extermination, arises what Vega (1988) dubs "Trujillo-Era Anti-Haitianism," based now on the physical presence of Haitians in the country and in the supposed threat to national culture. Vega indicates that following the Massacre [of Haitians in 1937], Trujillo "invoked anti-Haitianism as official policy", probably as a unifying factor by means of the manipulation of terror.

Situation of the Population Regarding Human Rights

The Dominican Republic has ratified the principal agreements and treaties of the Member States of the United Nations. This requires the nation to comply with the Universal Declaration of Human Rights, the Supplementary Convention on the Abolition of Slavery, the International Convention on the Elimination of All Forms of Racial Discrimination, the Convention on the [Political] Rights of Women, the International Labor Organization, etc. In addition, the Constitution of the Republic takes into account various aspects of civil and political rights.

However, the country has historically turned its back on considerations of people's rights, resulting in visits from human rights commissions, including that of 1976. As a result, economic sanctions were imposed on the country because the work conditions of Haitian's braceros were seen as the practice of slavery.

Regarding persons living with HIV/AIDS, their rights as citizens are allocated within the constituent regulations that govern the country, specifically AIDS Law 55-93 and internal bylaws. This law contains provisions regarding diagnosis, guidelines for prevention, the rights and duties of citizens whether infected or not, and sanctions against those who violates the rights and guarantees established by said law (Raful, 1995). López-Severino (1999) states that the counseling process is not regulated and that the task has often fallen to a handful of non-government organizations. Law 55-93 establishes counseling, but limits it to before and after the tests for HIV.

Cáceres et al. (1998) found in a survey that the majority of people living with HIV/AIDS in the D.R. remains anonymous because of the social and job implications of publicly acknowledging their stigmatized seropositivity. Existing self-help groups are concentrated in Santo Domingo, which limits the participation and empowerment of the immigrants in the bateyes. In many cases, the families of these people attempt to conceal their condition; others receive support on a small scale from their social networks. De Moya, Soriano and Rowinsky (1998) indicate that many infected persons as well as their family members and neighbors were unable to think about or pronounce the word AIDS without an intense emotional reaction, thus suggesting the ominous character that the term has acquired.

Cáceres et al. (1999) state that access to health services is conditioned upon the individual's purchasing power, on the private level. On the public level there is a serious lack of diagnostic instruments, protective measures, and medications. There are also problems with the willingness of health personnel to treat people who are infected. People who are HIV positive continue to be identified, stigmatized, and discriminated against within the health sector, and involuntary tests for HIV continue to be administered. Goyanes (1999) adds that antiretroviral medications are not available through the public health system. Laboratory controls for the proper use of these therapies are not currently available in the country, and appropriate training of health personnel for follow-up on patients undergoing treatment is deficient.

The HIV/AIDS Epidemic in Haiti

According to Farmer (1992), an analysis of the AIDS pandemic in the Caribbean reveals that it is composed of multiple sub epidemics of HIV transmission, initially derived from the broader pandemic in North America. Farmer states that epidemiological investigation has shown that the virus came to Haiti, the Dominican Republic, Jamaica, Trinidad and Tobago, and the Bahamas from the United States, probably by means of tourism and through migrants returning home from foreign stays. He believes that more powerful explanatory frameworks should reveal the transnational links that are evaded in many accounts based on national reports.

The first cases of AIDS on the island of Hispaniola occurred in the late 1970s and early 1980s (Guerrero, De Moya, Garib, Rosario, & Duke, 1985). Koenig et al. (1987) and Farmer (1992) identify sex tourism as the most probable route for the introduction of HIV/AIDS into the Dominican Republic and Haiti, owing to sexual contact between male homosexual tourists and Dominican and Haitian men who sell sex to men. De Moya and García (1999) add the link of organized homosexual tours with common destinations between Santo Domingo and Port-au-Prince for middle-aged North American and European tourists during the boom in the 1980s. This appears to be one of the oldest HIV/AIDS vectors on the island.

Two studies with female sex workers demonstrate that these workers had very high seroprevalence rates (over 60%), at least in some locations. Low-income groups (1989) and women patients at STD clinics up to 1993 surpassed a 10 percent infection rate, while this rate is almost three times higher (28%) in men with STDs. Parturient women under 25 years of age (1991-92) and pregnant women in at least two sentry posts (1992-93) had passed the critical level of 5 percent, suggesting a concentrated epidemic. Blood donors (1992) were close to that level. The PAHO/WHO report does not provide data for seroprevalence studies after 1993.

Two qualitative studies on the situation in Haiti have been published in recent years. Ulin, Cayemittes and Metellus (1993) studied Haitian women's role, in their country, in making sexual decisions. Their results demonstrate that there was little understanding of the danger of vertical transmission; women who have no way of earning a living were less respected and had little influence on decisions in the home and in sexual negotiations; interest in protecting the couple relationship leads many women to forgive or ignore the men's sexual activity outside the home; and women advise other women to abstain from any kind of sex with a promiscuous man, or even to leave him if unable to convince him to be faithful to her.

The HIV/AIDS Epidemic in Dominican Bateyes

HIV infection rates in different bateyes have varied considerably and are, therefore, difficult to compare. The principal risk factors identified for all dwellers of these communities are having had syphilis and the amount of time of residing in bateyes. For women, receptive anal sex, professional sex work, head-of-household status, and being younger than 35 were associated with risk. Half of the HIV positive women had not had more than two sexual partners (Brewer et al., 1996). Capellán (1992) and Brewer et al. (1996), found higher rates among Haitian subpopulations of both sexes, followed by Arrayanos and Dominicans. The first two of these three studies conclude that the majority of HIV transmission appears to occur within the bateyes.

Attempts to Establish HIV Preventive Action in Dominican Bateyes

Diligent attempts to prevent the transmission of HIV/AIDS have been carried out by Dominican national organizations such as PROCETS (Program for the Control of STDs and AIDS), SESPAS (Office of the Secretary of Public Health) (Mañaná & Gamboa, 1989), IDSS (Dominican Social Security Institute) (Arbaje, Cruz, Thormann, & González, 1992; Millord, Cize, & Arbaje, 1992a, 1992b), and the Reproductive Health Program of the CEA (National Sugar Council). Other non-government organizations have also participated, such as SSID (Social Service of Dominican Churches) and the donor agencies Medicus Mundi and PREVIHSA, the European Union's HIV/AIDS Prevention Project, to name a few. However, so far no reports or significant evaluations have been published that assist in understanding the concrete situation in the bateyes. IDSS hospitals offer general medical attention, and specialized attention is offered at the Salvador B. Gautier Hospital to insured Haitian braceros in the CEA and private bateyes, and to their wives and children as well. Early in 1999 the P. Juan Montalvo Study Center (CES) and the Jesuit Refugee Service (SJR) published a catalog of organizations and institutions that reported that they work with Haitians and with Dominicans of Haitian descent in the Dominican Republic. The catalog lists 41 non-government organizations (NGO's) and 14 ecclesiastical, seven peasant, seven union and five municipal community organizations.

The reality is that despite great efforts, we still do no not know the implications of these investigations and their significant results. From this standpoint we proposed for ourselves this project as a way of examining concretely the implications of migration for the HIV epidemic.

 

Method

The current study was carried out in three main phases: 1) Review of existing documentation on the relationship between Haitian immigration, HIV/AIDS, and the human rights of infected people; 2) Semi-structured interviews with key informants, authorities, and experts in the areas of concern; and 3) Eight case studies of Haitian immigrants living with HIV/AIDS in agricultural bateyes in the Dominican Republic, based on semi-structured interviews with these persons and/or confidants (close relatives and neighbors) who gave their informed consent to participation.

Two guides for semi-structured interviews were prepared, one for key informants and the other for immigrants from Haiti who are living with VIH in sugarcane agricultural bateyes. The guide for key informants consisted of 11 dimensions of the participant's experience and knowledge of the migratory routes from Haiti to the Dominican Republic, points of origin, stations, and destinations, variation and motivation for changes in traditional migratory routes over time, comparison of the HIV/AIDS situation between Haiti and the Dominican Republic, knowledge about violations of the rights of immigrants living with HIV/AIDS, community support, the role of magic-religious beliefs, available health services (including their quality and the level of satisfaction with them), the participation process, and discussion of proposed legislation on migratory control, etc.

The interview guide for people living with HIV/AIDS and/or their confidants consisted of 33 questions. These questions were on the following topics: demographic profile, migratory process, means of handling the lack of documentation, the human rights situation, the manner of detection of their infection, the condition of spouses and children, knowledge regarding the disease, symptoms, medical attention, social support and community relations, as well as any incidents of discrimination in the areas of employment, health, housing, and freedom of movement.

During the visits to the bateyes an observational context guide was also used, describing the communities being studied and illustrating the existence or lack of local services. This guide included a register for data regarding streets, housing conditions, sanitary facilities, electrical power, disposal of solid wastes (human waste and trash), schools, churches, business activity in the community, health services, internal community organization, and means of transport.

A list of possible key informants was compiled, including representatives of the Diplomatic Corps, Amnesty International, the International Labor Organization (ILO), the Office of the United Nations High Commissioner for Refugees (UNHCR), the Organization of American States (OAS), the Latin American Social Sciences Faculty (FLACSO), the Secretariat of Foreign Relations, the general management of Migration of Prisons, the National Committee on Human Rights, the Human Rights Commission, the Dominican Haitian Women's Movement (MUDHA), the Haitian Workers' Sociocultural Movement (MOSCTHA), university professors and social communicators.

We were able to carry out five semi-structured interviews with key informants who had experience in community work with immigrant women and Haitian prisoners, migration, foreign relations, and human rights. A sixth interview dealt with AIDS-related funeral rites in the bateyes as a magic-religious cultural expression. These interviews were recorded with the permission of the interviewee, and were then edited, summarized and tabulated for individual and group analysis.

The next phase consisted of an exploration, through semi-structured interviews, of the experiences of Haitian immigrant men and women who were HIV positive or had AIDS. To this end we contacted health personnel of the National Sugar Council (CEA) and of community organizations with whom the authors had previously carried out preventive actions between 1992 and 1997. Their collaboration was requested in recruiting patients of theirs who would be willing to give them orally their informed consent to participate in the study, voluntarily and anonymously. The consent included that the spouse, children, and other confidants could participate as interpreters, if the person being interviewed did not feel that this violated his/her right to privacy and confidentiality. Doctors, nurses, and health educators were given training to prepare them to explain to the candidates the purpose and objectives of the study, and to obtain the informed consent of the patients. In one case, in which the patient was in the terminal stage of the disease, his wife and children consented to give the interview. Selection criteria included being born in Haiti, being HIV seropositive or with AIDS, and living in batey colonies.

In the end, four semi-structured interviews with women and four with men were held in their homes. These interviews were also recorded with the patient's authorizations, edited, summarized, and tabulated for analysis. The research team provided antiparasitic medications, condoms, and educational materials to the health educators in each batey they visited, to be distributed later to the inhabitants.

To complete the gathering of data for the eight case studies, additional individual interviews were carried out as key informants (confidants) with 10 neighbors, an evangelical pastor, one husband and one wife of patients, one sister-in-law, two community leaders, three health educators, one nurse, three medical doctors, and two batey supervisors.

The analysis strategy included the three phases of the study: first, the documents were studied (laws and treaties, books, university theses, organizations' reports, and newspaper clippings); second, the semi-structured interviews with key informants were analyzed in terms of recurring themes and their reciprocal relationships; and third, the same was done with the semi-structured interviews with the Haitian immigrants who were HIV positive or with AIDS and their confidants.

 

Results

Interviews with Key Informants

Those interviewed agreed that, in general terms, the magnitude of the AIDS epidemic in Haiti is greater than in the Dominican Republic. They emphasized that health conditions are very poor and unsanitary in that country, with little access to health services, and they acknowledged that living conditions were similar in the Dominican bateyes, where Dominicans, Arrayanos and Haitians live together.

The participants reported violations of the human rights of the immigrants in general, such as bribes being demanded in order to cross the border, women being deceived and raped there, the postponement of rape lawsuit trials, the absence of women from the sugar mill payrolls, and the denial of housing to women unless they had children old enough to cut sugarcane.

Three informants reported knowing of cases of persons with HIV/AIDS, both Haitians and Dominicans, in the bateyes. One of the informants stated emphatically that "the right they have is the right to die, because there isn't anything else for them in the batey." They reported various human rights violations, such as the restriction of their freedom of movement (the inhabitants obstructed their access to the community), the avoidance of physical contact (leaving food for them from a distance, without coming near), compulsive sanitation (washing for a long time the containers from which the sick people ate), discrimination (health personnel not providing medical help or making excuses for not giving it), and ostracism (deporting Haitian residents who were HIV positive when they attempted to renew their visitor's permits). They also mentioned having little access to health and education services.

Some of those interviewed, however, considered that the isolation or the release of infected prisoners from jails and the deportation of seropositive foreigners were done with the consent of HIV positive persons or as a response to pressure from groups and communities.

According to the informants, the response of the Haitian population to the HIV/AIDS crisis in the Dominican Republic is conditioned upon the rights that the country and its institutions recognize or deny to them. One of the informants explained that "historically, a Haitian is not treated like a person" in the Dominican Republic. This is in addition to the stigma attached to the condition of being HIV seropositive, whatever one's nationality. They mentioned ignorance of the right to nationality for their children bon in the country, to the lack of legal documentation, and to the lack of immigration officials who speak Creole.

The main obstacles faced by this population, in the judgment of those who were interviewed, are the language barrier, the deplorable living conditions (sanitation, housing, education, health), the high illiteracy rate, and the widespread use of the sex trade as a survival strategy.

They acknowledged that when they arrive in the Dominican Republic, the majority of Haitians do not appear to have any intention of returning to their own country, and they keep moving from place to place in order to escape migration controls and insert themselves into other productive areas. They focused on popular religion as a facilitator, in some cases, and an obstacle in others, to AIDS prevention and treatment. They believe that people resist accepting their own illness, believing that "somebody put a curse on them".

Regarding HIV/AIDS preventive action in the bateyes and other areas where the Haitian population lives, the informants said that the organizations that work with them should take a greater interest in making this topic a priority. They suggested preparing educational messages in two languages, Spanish and Creole; distributing prophylactics; improving the quality of life of infected persons, assigning not only economic resources to that task but also trained and sensitized human resources. They also propose providing basic medications to people who are seropositive, Haitians as well as Dominicans.

One of the informants, however, argued that "it is not the government's responsibility to give health care to foreigners, because it would be impossible to cover the high cost that that would involve". This person expressed a strong interest in learning the true scope both of the Haitian migration and of the HIV epidemic among immigrants.

The representatives of the participating organizations declared that there was little coordination among them regarding human rights work. Three of them characterized these groups as being interested only in denouncing irregularities (imprisonments, deportations, repatriations). Only two of them related having carried out joint actions, such as presenting proposals for discussion within the process of the National Dialog, and accusations before the United Nations High Commissioner for Human Rights. Two of the institutions related to the governmental area are in the process of revising or discussing migration laws with a view toward a new project and a common agenda between the two nations, for a new meeting of the two Heads of State.

Case Studies of Persons Living with HIV/AIDS in Dominican Bateyes

The ages of the female HIV positive cases interviewed were between 24 and 45. They were women who had not mastered Dominican Spanish, could not read or write, and whose work before becoming ill was "selling things", washing and ironing clothes for money, or picking coffee on small private farms (conucos). They report having had two to five serial monogamous unions, and each had three or four children by different fathers. Two women had small children with signs and symptoms of HIV infection. Two had been widowed from men who they suppose died of AIDS. One of them knew that he had been infected by a former wife who was HIV positive. The two infected women had both formed unions immediately with other men of the batey. The other two women were also living with partners. Some of them had met their partners in Haiti and others in the batey where they live.

Three of these women had entered the Dominican Republic from Haiti by land, and one had come by sea; they had come from towns in the north and the south, to different Dominican communities. They made at least two migratory stations before settling where they are now. All of these women were without documents. However, they said that they went wherever they wanted without being bothered by immigration agents or being asked for their papers. On the other hand, they tried not to attract much attention in the community. Several of the women interviewed said that Hurricane Georges "took away my papers".

Three of them said that they felt sick with fever, diarrhea, parasites, kidney infections, skin problems, and "stomach problems". None of them mentioned the word AIDS. Only one, whose infection was detected during her last pregnancy eight months ago, claimed to have no health problems, but her baby "is always sick". All had sought medical attention. This attention was short term in two cases; in another, when she gave birth; and in the other, systematically in recent days. They had received help from husbands, children, in-laws, neighbors, and religious pastors. The interviewed women complained that no one had told them that they had to go back to the doctor, that no one gave them medications, or that they had no money to go to the doctor or to buy medications. They said that they had not had problems with the community or with health or immigration officials. People visited them, they give them food when they could, and they helped with some of the household chores. They reported that they were treated well at the health centers where they had gone. Sometimes they were seen quickly, but apparently they were not examined with care nor did anyone pay much attention to them. These centers lacked medications and the necessary equipment to examine the patients. The women generally had to leave their communities to gain access to health services.

The ages of the four men who were interviewed ranged from 37 to 63 years. Health educators and neighbors, with the consent of everyone except one patient who was in the terminal stage, helped spontaneously as interpreters, as had been the case with the women. The men lived in agricultural bateyes; two of them lived with a woman and children. Although they had wives before, two of the men were living alone, without a relationship with a partner. In one case, his wife had left him and formed another union with a neighbor, although she visited him and gave him things to eat. The other received weekly visits from his wife and children, who lived in another batey and who brought him food.

The migratory routes that they used were at the border, from the north and from the south, and in one case, by sea, landing in Pedernales. All but one had lived in various migratory stations. One of them claimed to have walked almost all over the country, reporting 15 places of residence. Three came alone and one came with his wife and a small child, to work cutting sugarcane in the bateyes. All were without documents, although they had been living in the country for more than 10 years. As to their handling of the lack of documents, none mentioned having had problems with the authorities.

These men said that they felt sick with "amoeba", "colerín" (little cholera), and diarrhea. One explained that his illness was due to a blow on the head that he had received years before. In no case did anyone mention the word AIDS. Two of them said that they had been tested for HIV in public hospitals. One was retired. In general, they did not know exactly what sickness they had or why they were sick. One said that he had hopes that God would take away his illness. All of them had quit working in the cane fields due to their illness, but some of them planted yuca and batatas in small conucos "to have something to eat".

All four reported having sought medical attention within or outside their community, or by means of a health educator. One showed how happy he was to be taking medications. Another went to a nearby batey for a medical consultation, but neither personnel nor medications were available. All received food from their families. They said they got along well with the rest of the community. In one case, a neighbor said that people took care not to let children step on his saliva nor sit where he sat. In another case, the man had to be moved to another house, apparently over conflicts with a neighbor related to his seropositivity.

 

Discussion and Conclusions

Immigration, HIV/AIDS and Human Rights: Tomorrow will be too Late

The principal studies consulted and the data from the case studies tend to support the notion that most HIV transmission takes place in the Dominican bateyes, rather than as a product of new waves of Haitian immigrants. Dozens of new HIV positive cases in the disease phase are appearing in these communities where abject poverty holds full sway. Every day more adults and children die without knowing exactly what they have or how to find relief for the suffering caused by the disease.

The human rights situation of people living with HIV/AIDS is a product of the history of general ignorance regarding civil rights among the Dominican population itself; of the lack of a migration policy that respects human rights; of the history of conflicts between the two nations; and of the generalized stigmatizing of HIV/AIDS. As one key informant declared, the only right that people who are HIV positive appear to have in the bateyes — Dominicans as well as Haitians — is to die, without ever even knowing what they are dying from or why. A substantial number of them are mothers who become infected and infect others due to the need to maintain serially monogamous relationships as a survival mechanism.

Flexible, Dynamic, and Changing Migratory Routes

The migratory routes from Haiti and their destinations in the Dominican Republic are many and varied, involving diverse areas of the host economy and new means of clandestine access, such as by sea. The interviews with key informants and the case studies show two main migratory routes, one in the south and the other in the north. The migratory currents cross the border primarily through checkpoints and local roads. The intensification of the migratory flow appears to depend on the precise political and economic situation of the two nations. However, the process looks like a permanent phenomenon of osmosis of part of the excess of the Haitian population toward Dominican territory, as a result of the ecological degradation of Haiti. This excess will continue to assimilate culturally and ethnically with the Dominican population through their descendants, who within two generations will be impossible to distinguish from either group. The Arrayano population, lasting only one generation since its children will be Dominicans, will continue to increase.

Recognition of the Role of Poverty in Facilitating the Epidemic

The intensification of the pandemic in the bateyes occurs mainly because of the conditions of poverty and inequality in which its inhabitants are living and which increase their vulnerability to the infection. A history of syphilis in persons of either sex and, in women, sex work, anal sex, head-of-household status, and youth are recognized as individual risk factors for infection. But the fact of a woman's being the head of the household requires a more structured and deeper analysis, which goes beyond the objectives of this study. An epidemiology that localizes the "blame" for the spread of the virus in the victims themselves, solely because of their individual behavior, is an epidemiology that attempts to ignore social structures such as poverty, which may be the most important risk factors, perhaps even greater than the effect of undocumented migration.

As did Aggleton and Bertozzi (1997), we found in this study that in the Haitian homes we examined, which included at least one family member infected by HIV, changes had occurred in the socioeconomic structure and the functioning of the family, such as the loss of employment for pay, low levels of seeking attention, and denial, ostracism, and partial desertion. Nevertheless, probably because of the abject poverty of the cases, there has not been any increase in taking out loans, nor in selling possessions as the illness becomes more serious. Farmer, Connors and Simmons (1996) reminds us that although the majority of epidemiologists still do studies in populations, they do so in order to study individual, decontextualized risk factors, instead of studying population factors in their historical and social context. Recognizing the role of poverty is contextualizing individual "risk" behaviors in the "pandemiology" that we use to describe HIV/AIDS.

In conclusion, these considerations reaffirm the belief that the epidemics in Haitian territory and in Dominican bateyes are closely linked. Increases in the prevalence rates in Haiti should correspond to increases in the rates of infection among the new immigrants entering the country. However, the epidemic situation in the bateyes allows for an inference that there is a high risk of infection for the susceptible Dominican, Arrayano, and Haitian populations, particularly women and young people entering the country and natives and residents who are beginning to be sexually active. Likewise, each year repatriated Haitians should have, in consequence, rates of infection that are probably higher than those of immigrants who come to the Dominican Republic for the first time.

 

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Irene López Severino. Licensed clinical psychologists with a masters degree in social-community psychology at the Autonomous University of Santo Domingo. She has participated in research studies addressing assistance of people living with HIV/AIDS and human rights. E-mail: irenelopezs@verizon.net.do
Antonio de Moya. MA degree in psychology and public health. He is a member of the Presidential Council on HIV/AIDS (COPRESIDA) and the Transcaribbean HIV/AIDS Research Network. His research interests include pandemiology, ethnography of sexuality, social prejudices, youth gangs, and HIV/AIDS. E-mail: tdemoya@copresida.gov.do.
¹ Dirección: irenelopezs@verizon.net.do, tdemoya@copresida.gov.do.
² This paper was initially presented as a report to the Latin American and Caribbean Council of AIDS Services Organizations (LACCASO) and the Joint United Nations Program for HIV/AIDS.
³ From the Spanish "raya," meaning "line" or "border; refers to Dominican-born children of Haitian or Haitian and Dominican parents. The term is not considered pejorative.