In Cap-Haïtien, Haiti, everyone rises with the roosters, and by 8 a.m. the unpaved streets outside Hospital Justinien are jammed. Taxicabs and pickup trucks, some painted with religious slogans and turned into makeshift buses called taptaps, jostle for space on the narrow thoroughfares, dodging potholes and negotiating chaotic corners unregulated by traffic lights.
Amid the exhaust and swirls of dust, pedestrians hustle alongside the roar of traffic. Men push wheelbarrows filled with electronics and blocks of ice. Women balance trays of eggs and bananas atop their heads. Little girls hurry on their way to school, dressed in neat white blouses, kilts and lacy socks, a half-dozen bows in their hair.
On Tuesday, trash day, towers of raw garbage stand on the sidewalk, ready for collection. Goats and the occasional pig scale the piles and nibble at scraps of food and cardboard. Shopkeepers sweep carefully around the waste before raising their storefront grilles.
Here on Haiti's northern coast, 150 miles from Port-au-Prince, life goes on in the country's second-largest city, much as it did before January's earthquake, and another working day has begun.
Inside Justinien's pediatrics ward, high-barred windows keep out the harsh morning light, and thick concrete walls seal off the noise. Hot, humid air settles over rows of cribs where babies, some attached to I.V. drips, lie near watchful mothers.
A small room off to the side is bare except for an examination table, a makeshift desk piled with folders and bottles of medicine, and two narrow wooden benches pushed up against the walls. A tall Haitian nurse wearing a white dress and a cap and stockings, straight out of the 1950s, confers with a smaller, wiry American woman over a pair of height-and-weight charts.
The Haitian is Miss Gourges, head nurse of Justinien's infant-malnutrition clinic. The American is Dr. Patricia Wolff, a St. Louis pediatrician. Wolff is 62 years old. She has large blue eyes, short blond hair, a pointed chin — and a commanding presence. As her friend Mary McElwain puts it: "Pat is a person who feels people should listen to her."
Wolff has a black belt in Kenpo karate and usually carries a stun gun and a can of pepper spray in her purse. She is a woman to be reckoned with. Two months ago, when someone snatched her iPhone from her front pocket, Wolff hopped aboard a motorcycle taxi and chased the thief through the streets of Cap-Haïtien until he disappeared into a market.
One of the charts Gourges and Wolff are studying shows that a healthy 10-month-old baby should weigh 5-and-a-half kilograms, a little more than 12 pounds. "That's not right," Wolff says. "I know how much a 10-month-old is supposed to weigh."
The child is Robenson Yean, who sits on a narrow bench beside his mother. He wears a dirty brown T-shirt and a pair of shorts. He is unusually small for his age. His face and belly are swollen, and there are tiny dark spots on his feet, all telltale signs of malnutrition.
Gourges, with the aid of the height-and-weight chart provided by the World Health Organization, has determined that Robenson is indeed malnourished and eligible for Justinien's treatment program, sponsored by Wolff's organization, Meds & Food for Kids, also known as MFK.
Over the next month and a half, Robenson will make weekly visits to the clinic. Gourges or another nurse will wrap him in a sling and hang him from the scale suspended from the ceiling. They'll stretch him out beside a ruler to calculate his height — a delicate operation, because, as Wolff points out, even a centimeter can alter his ideal weight.
The nurses will mark the boy's progress on a chart; Justinien, like most institutions in Haiti, has no computers. Then they'll hand his mother a green-plastic packet containing half a kilogram (1.1 pounds) of medika mamba — "peanut butter medicine" — which she'll feed to Robenson. By his next visit, he'll likely have gained a few ounces, and gradually he'll reach a healthy weight.
It is medika mamba that brought Wolff to Cap-Haïtien. For seven years, she's been working to build a factory where Haitian workers will use the peanuts grown by Haitian farmers and transform them into peanut butter, enhanced by vitamins and minerals, which will be fed to malnourished children in clinics throughout Haiti.
A few minutes before Robenson and his mother arrived, Wolff and Gourges were studying the chart of another child, a one-and-a-half-year-old boy named Blaise. He weighed 13-and-a-quarter pounds when he began, and his goal weight was set at 16-and-a-half pounds. At his last visit, though, he weighed only a little more than 14 pounds.
The numbers make Wolff suspicious. When used properly, medika mamba has a 75 percent success rate.
"Maybe he had diarrhea," Wolff speculates. "Or maybe his family was giving [the medika mamba] away. He missed two visits. They gave him a warning. He was supposed to be kicked out if he missed a visit, but the kid probably looks so sick and scrawny they decided to keep him in."
Without more good outcomes, Wolff won't be able to prove to potential donors back in the U.S. that medika mamba is the best way to fight childhood malnutrition in Haiti. Without donations, MFK won't be able to build a new factory. Without the new factory, it won't be able to produce sufficient quantities of medika mamba to sell to big aid organizations such as UNICEF and USAID.
And without turning a profit, the factory will never be self-sustaining and will, like so many other projects in Haiti, find itself completely dependent on foreign aid.
That is precisely what Wolff does not want.
"Shoot, you need to stay and develop the country," she says. "They don't need to be rescued."
Nothing had prepared Pat Wolff for her first trip to Haiti, in 1988. "It felt as though I was at the scene of an accident," she remembers.
She'd traveled to Port-au-Prince with the Haiti Project, a mission group led by Bob Corbett, a retired Webster University professor who had become an expert on Haiti, and his wife, Jane. Wolff and her husband, Michael, now a Missouri state Supreme Court justice, and their two sons, then 11 and 14, planned to volunteer at Mother Teresa's homes for dying children and adults.
"It was a profoundly awful experience," Wolff recalls. "Most of the people there were dying of something that could have been treated with proper equipment: tuberculosis, malnutrition, infections. All we could do was comfort them as they needlessly died. It was way too little and way too late."
Corbett arranged for Wolff, another doctor and a nurse to travel into the mountains to volunteer at a start-up clinic. They rode horses and donkeys and brought all the medicine they could carry.
"The first day, 300 people showed up," Wolff. recounts. "Some of them had walked miles and miles. They had never seen a doctor before. They had heart disease, kidney failure. It couldn't be solved with a Band-Aid. It was eye-opening and upsetting. I went home bedraggled and grief-stricken."
Over the next 15 years, Wolff returned often to Haiti, mostly to a clinic near Cap-Haïtien. But, she says, "It was like spitting into the ocean. We needed to solve the underlying problem." One in five Haitian children, Wolff learned, is malnourished. One in 10 dies before his fifth birthday.
"Malnutrition leads to immune deficiencies," Wolff explains. "They got diseases because they were malnourished."
One of Wolff's colleagues at Washington University's medical school, Dr. Mark Manary, had been experimenting in the east African nation of Malawi with a radical new treatment for malnutrition. A combination of ground peanuts, powdered milk, sugar, oil and vitamins, it was cheap, easy to produce and high in protein. It was also easy to store, even in a tropical climate. Best of all, patients could be treated at home.
"The only treatment for malnutrition [in developing countries] was in the hospital," Wolff explains. "People would wait in the hospital for months. There was only a 20 or 25 percent recovery rate."
Manary doesn't know why it took so long to come up with the peanut butter solution. "In the Middle East," he says, "they've been using halvah, the same notion, for 2,000 years, but we didn't come to it so fast."
But he and his research partner, André Briend, saw immediate results. From the earliest trials, the peanut butter, known in the scientific community as ready-to-use therapeutic food (RUTF), showed an 85 percent success rate. Amazingly — again, no one is sure why — peanut allergies are rare in the developing world. By 2007 the World Health Organization declared RUTF the gold standard in treating childhood malnutrition.
Manary and Briend decided that if RUTF were to be of any use, it would have to move beyond research studies and into mass production. Briend established a partnership with a French company called Nutriset, which would manufacture the peanut butter, called Plumpy'nut, in its Rouen factory and export it around the world. Nutriset now controls 90 percent of the world RUTF market.
Manary, however, saw RUTF's potential for economic development, and by the time Wolff visited his Malawi clinic in 2001 and 2002, he'd already started his own NGO, Project Peanut Butter. The organization would buy peanuts from Malawian farmers and produce RUTF in a local factory. There was no way Project Peanut Butter would be able to compete with Plumpy'nut on a global scale, but it would provide jobs and pump money back into Malawi's economy.
Wolff liked what she saw, and with Manary's help, she started her own program. She got a grant from Rotary International, and she purchased a peanut grinder. She learned how to operate it, take it apart and put it back together. "It was a little tricky," she says. "But now I was set. I could go to Haiti."
She set up the grinder in a church classroom in Cap-Haïtien and began making peanut butter.
At 7 a.m. Wolff leaves for the factory, a house in the Cap-Haïtien suburb of Mombin Lataille, and arrives in time for the daily morning meeting with the factory supervisor. "We talk about who's going to use the one car because the other car's been broken for a week," she says. "I talk to the quality-control manager. I talk to the product supervisor, and we figure out how much medika mamba we need. We check to make sure we have the right kinds of bags and cups in storage."
A problem that, in the United States, might be solved in a single afternoon can drag out into a monthlong saga in Haiti. MFK's broken Land Cruiser, for instance, needs a rubber seal for its engine. None of the Cap-Haïtien mechanics can afford to keep parts on hand; the seal has to be specially ordered from a dealer in Port-au-Prince. When the part arrives and doesn't fit, a replacement has to be ordered from the Dominican Republic. When that part doesn't work, the mechanic offers to use a lathe to make it fit.
That's the Haitian way, though: Improvise solutions with what little you have. It's very different from America, where, Wolff notes, "Our ability to solve problems comes at our mother's knee. We have resources. In a land with nobody to ask and no stuff to buy, you can't solve the problem."
Most Haitians cook their meals in iron pots over a charcoal fire. Electricity is spotty. There are no newspapers. Most of the roads were built during the American occupation in the 1920s and '30s and haven't been repaired since. And, adds Jamie Rhoads, MFK's agricultural-development specialist, "The wonderful, corrupt government makes things even more tricky."
MFK has experienced its own share of disasters. For several years now, Wolff has been working to bring the factory up to international food-safety standards. It's a necessary measure so that MFK will have credibility with UNICEF and USAID, which are accustomed to Plumpy'nut's First World facilities in France.
"We needed stainless steel," Wolff recalls. "There's no stainless steel in Haiti. It all had to be imported from the Dominican Republic. The Easter before our audit, there was a fire. The plumber had hooked up the propane fridge wrong, and there was a leak. On Sunday afternoon — kaboom! The whole place went up in flames. There was nothing left. Everything had disintegrated. That was two years ago. We had to replace everything in the lab and restore the house to its previous status. It cost $30,000, a huge amount of money for us."
Neighborhood bucket-brigade members who had put out the fire had also made off with MFK's car keys. There was nothing to do but fly back to St. Louis and organize a fund drive so they could start all over again.
"The culture of work is different," Wolff reflects. "It's difficult to get across the idea that the American idea of work is much more strict. We've had to impose our idea of work — and the Haitians consider it imposing. Showing up to work for a boss is a foreign concept. A lot of Haitians work for themselves. The employment situation has an underlying theme: We will never be slaves again."
One morning last month, Wolff and several staff and board members went to a Haitian notary's office to buy a one-and-a-half-acre parcel of land for the new factory. They brought with them a pile of paperwork and a check for $157,500. They left an hour later, without a deed for the property. The paperwork was insufficient, the notary told them. They needed to fill out more forms and produce more signatures. The owners needed to be present.
It took two more weeks for the deal to go through. Although Haitian law states that the notary fee should be 1 percent, the notary tried to charge MFK 5 percent, an additional $7,875, for his services. Wolff negotiated him down to 4 percent on the grounds that MFK is a nonprofit.
"If it had been Haitian-to-Haitian," she says, "it would have been 3 percent. But that's the way things are done. It's a Robin Hood idea."
Last August the peanut butter factory finally passed its international food-safety inspection. Still, it received the rating "adequate but suboptimal" in so many categories that the phrase has become a joke among the MFK staff.
That it exists at all, says Lori Dowd, a documentarian working on a film about MFK, "is a fucking miracle."
Shada is the worst slum in Cap-Haïtien. It sits on what used to be a mangrove swamp. Now there's a riverbank made of garbage. The air smells like the inside of a Dumpster, with top notes of human waste. Naked babies sit by themselves in the dirt alleys, playing in shit. No one in Shada has a job. No one goes to school. A little girl wearing nothing but a T-shirt dances for money. Her hair has turned red from protein deficiency.
Madame Bwa, the neighborhood midwife, has organized classes on hygiene and sex education, but she can't treat worms, tuberculosis or malaria. None of her patients can afford the 50 cent taptap fare to the Justinien clinic.
A doctor who comes to Shada holds office hours for two hours a week. It's not nearly enough. Usually there are more than 100 patients waiting to see him.
"It's hard to see kids die of malnutrition after getting called in the middle of the night to bring them into the world," Bwa says (in Creole, with Rhoads translating).
The Shada clinic rarely receives medika mamba. A 1.1-pound bag costs $2.50. Few residents can afford to pay for it, and MFK can't afford — at least, not yet — to donate it. In addition to the $2 million for the new factory, the organization requires $66,000 a month just to stay afloat.
"We need to keep growing," says Steve Taviner, MFK's director of development, who works in the St. Louis office. "This is what makes the new factory imperative. We've hit the wall for how much we can make. With the new factory, we can make four or five times as much more cheaply and efficiently. In five years, we want to be the primary supplier of RUTF in Haiti."
Though MFK's sales have been steadily increasing, Taviner says they only account for one-third of the organization's overall revenue. Most of the funding still comes from donations, from places like Google, Nestlé, Christian World Relief, the Macaulay Foundation, Novus International, Scottrade and Emerson Electric. Inmates and employees at three federal prisons in Illinois read about MFK and raised $2,200.
"In many ways, ironically, the earthquake was a remarkable opportunity," Taviner says. "It raised lots of interest and funds. The phone was going nonstop. We've raised $1 million since January 12."
By the end of next year Wolff hopes to build a new factory capable of producing enough of the peanut butter supplement to be able to supply UNICEF and USAID, the two biggest aid organizations in Haiti. It's a project that Wolff estimates will cost $2 million. MFK has raised half that amount already.
Wolff also hopes to set up a "farmer school" where MFK will till the soil and plant peanuts. Different plots will have different growing conditions, and the Haitian farmers will be able to see which strategy works best. Wolff wants to be strict: "We'll tell them, 'We will buy your peanuts, if you will do it right.' "
Wolff is still looking for donors. "I almost got on Oprah," she wisecracks, "but they went for star power, with Wyclef Jean instead. God knows why." She continues more seriously: "The development business is very complicated. It's not filled with altruistic people. But there are people within it who are altruistic. We need to find those people and have them pull the levers."
Six weeks ago, though, Wolff decided she needed to take a more radical step. The day after the land purchase was delayed, she got on a plane to Rouen to meet with executives from Nutriset, the parent company of Plumpy'nut, MFK's chief competitor in Haiti.
Nutriset once owned a 50 percent interest in Vitaset, a Plumpy'nut franchise in the Dominican Republic. "I made everybody feel bad about importing from the Dominican Republic," Wolff says. She's not entirely joking. But now Wolff wants to talk about becoming a Nutriset franchisee.
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Working with Nutriset would give Wolff access to UNICEF and USAID. "Plumpy'nut taught UNICEF everything about RUTF," she says. "UNICEF takes its orders from Nutriset. We're trying to get the best deal we can."
In order to do that, Wolff is willing to compromise. MFK will start using Nutriset's peanut butter recipe. "It's a trade secret," Wolff says. The size of the peanut butter packets will also shrink. "Nurses prefer the bigger packets," Wolff says. "That way your neighbors won't ask you for [an extra packet]. You're not supposed to share. But UNICEF is the biggest buyer in the world."
More significantly, MFK will have to alter its plans for the new factory to meet Nutriset's production demands, which means more equipment and more training for the workers.
"It's the way to a sustainable future," Wolff says. "We're having growing pains, but we need to make it happen. It's a bigger and more complex vision than we had before. It's kind of exhausting, but it's never boring. Boring could be worse."