HealthPublic health politics in Haiti have been dominated for decades by the Boulos family. The patriarch of this influential and wealthy family, Carlos Boulos, MD, founded a nonprofit organization known by its initials CDS (in English: the Center for Develop ment and Health) in the 1970s. Adroitly securing funding from diverse sources such as the WHO and the US Agency for International Development, CDS became an important public health and primary care organization serving the poorest of the poor in Haiti. Johns Hopkins professor Neal Halsey s work in Haiti was largely conducted under the auspices of CDS.

Carlos Boulos had three sons. Reginald ran CDS after his father’s death, and it was he who supported and collaborated with Halsey on studies of new vaccines and HIV, among other projects. Reginald’s brother Rudy ran a pharmaceutical manufacturing company named Pharval. The youngest Boulos brother, Franz, ran a cosmetics firm.

As NCID officials began speculating on the possibility of DEG contamination as a source of the epidemic, they shared their suspicion with Halsey. He, in turn, shared the С DCs suspicions with Reginald Boulos, who mentioned them to his brother Rudy. The С DCs suggestion that someone begin collecting medication bottles from those currently ill and recently deceased led to an offer by Rudy Boulos to have his labs at Pharval test the samples. Kate O’Brien told Halsey in no uncertain terms that this should not be allowed, pointing out that the source of the contamination was still not known and that Pharval may have been involved.

Observers, including O’Brien, have been impressed with the ability of the Boulos family, especially Reginald and CDS, to survive within the volatile political climate in Haiti over the past three decades. “They never wholly aligned themselves with anyone, and they avoided making enemies,” according to O’Brien.
Nonetheless, in the year before the outbreak of the epidemic, there had been increasing signs of strain between Reginald Boulos and Jean-Bertrand Aristide’s government. According to the New York Times,

once Aristide returned to power in Haiti in 1994 after having been ousted in 1991, his supporters denounced Reginald Boulos as an associate of the Tontons Macoute, paramilitary thugs who had flourished under the 30-year Duvalier family dictatorship and its military successors. Boulos disputes this charge, as do some outside observers. Boulos acknowledges that during the three-year period between Aristide’s 1991 overthrow and 1994, when American troops restored Aristide to power, he tried not to antagonize the military regime in order to protect CDS and its programs.

As Rudolph Mallebranche, Haiti’s new Minister of Health, attempted to regain control over the delivery of health care services in Haiti, Reginald Boulos and CDS fell out of his favor. In 1995, at Mallebranche’s bequest, РАНО had launched an investigation of pharmaceutical manufacturing companies in Haiti, including Rudy Boulos’ firm, Pharval. In September 1995, Rudy Boulos and Pharval were heavily criticized in а РАНО report on the operations of the country’s three pharmaceutical manufacturers. Although Rudy Boulos was inclined to dismiss the investigation as politically inspired, РАНО consultant and industrial pharmacist Ludo Martens described the Pharval operation as “a plant which has fallen asleep.” Ironically, FDA and CDC investigators later learned that the РАНО inspection took place the very month that the first lot of DEG-contaminated acetaminophen syrup was produced in Haiti.

CDC Personnel Arrive

When Kate O’Brien arrived in Haiti on Friday, June 14, 1996, to launch the epidemiologic investigation, she immediately went to the General Hospital, where she met with pedia-tricians and epidemiologists to discuss the approaches they would employ to

pinpoint the cause(s) of the epidemic. The weekend of her arrival, a physician with whom she had worked in Haiti in 1991 dropped off the medications he had collected from two children then in the hospital with renal failure. She noticed that both children had taken Pharval acetaminophen preparations, one labeled Afebril and the other Valodon. She also noted that the two drugs had sequential lot numbers, but she was not sure whether this had any significance.
O’Brien was soon joined by a colleague from the С DCs National Center for Environmental Health, Joel Selanikio, MD. Selanikio, also a member of the “Class of ’95,” would conduct the investigations of pharmaceutical companies, including Pharval. By the time Selanikio arrived in Haiti, O’Brien and her colleagues suspected that the epidemic was due to DEG contamination and that Pharval’s products were involved. In an increasingly tense situation, Selanikio’s arrival freed O’Brien for the ongoing medical effort.

The CDC investigators recall with grim humor that in Haiti, in contrast to everything they had learned at the CDC, the epidemic did not stop the moment they arrived. O’Brien and Selanikio worked with a tremendous sense of urgency. Children were dying before their eyes, usually within approximately three days of admission, and approximately three children were being admitted to the General Hospital every day.
Efforts to treat these children proved nearly impossible. By the time that O’Brien arrived in Haiti, equipment for performing simple peritoneal dialysis was available. This technique would have been safe, effective, and adequate had the Haitian children merely suffered from renal failure. Renal failure, however, was not the only symptom requiring treatment; most of the children suffered from symptoms such as severe vomiting, hepatitis, pancreatitis, neurological problems including respiratory failure, facial paralysis, encephalopathy, and

even coma. The General Hospital in Haiti was not equipped to offer intensive care for these multiple, life-threatening conditions.
Into this void stepped a group of nephrologists from the University of Michigan led by Tim Bunchman, MD, and Rulan Parekh, MD MPH. Upon learning of her son’s prognosis, one Haitian mother had contacted UNICEF and other international relief agencies asking for help in saving her child. The International Services of HOPE responded by flying her two-year-old son to Ann Arbor for treatment. After two weeks of intensive care for neurological problems as well as renal failure, the child was alert, active, and recovering. Working largely over the Internet, Bunchman and his colleagues located medical centers that agreed to provide intensive care services for the Haitian children, and the International Services of HOPE arranged to Medivac as many children as possible to the US for treatment. Of 98 children who remained in Haiti with anuria (inability to urinate) and renal failure, 11 were removed from the hospital, presumably to die at home. Of the remaining 87, only two survived. Eleven children were flown to the United States for intensive care. One died in flight, and two died shortly after arrival. Two more died later, but the remaining six survived and made full recoveries following intensive treatment.