by Paul Farmer
AIDS was not only the leading cause of adult death in many of the places we worked; by the year 2000, it surpassed tuberculosis as the world’s leading infectious killer. As we showed in central Haiti, effective diagnostics and therapeutics for AIDS could be delivered to even the most destitute sick with the help of community health workers.5 But few seemed interested in funding AIDS care in poor countries. Policy debates pitted prevention against care—as if these were competing priorities rather than complementary ones—and many thought doing both would be too expensive. Partners In Health had been able to finance AIDS treatment in central Haiti because of the generosity of people such as Tom White, a Boston contractor who had given us millions of dollars over the years. But dependence on angel investors wasn’t going to save millions of lives in Africa, much less integrate prevention and care and strengthen weak health systems. “You need billions, not millions, of dollars,” Jeff Sachs, a development economist and colleague at Harvard, observed.6
In December 2000, Sachs and his wife, Sonia, a pediatrician, came to central Haiti to meet some of our AIDS patients, most of whom were flourishing with the help of antiretroviral drugs—the very drugs that many health policy experts argued were too difficult to administer in such poverty-stricken settings. On the spot, Sachs promised to work with the United Nations and several governments to create new funding mechanisms to respond to AIDS, tuberculosis, and malaria, three diseases that by 2001 were claiming six million lives a year. He kept his promise. I was lucky enough to travel to New York with the Haitian delegation, led by another health advocate, First Lady Mildred Aristide, to the first UN general assembly on AIDS. We collectively pushed for new resources to respond to what was then a fairly new and now global threat. A group of Harvard faculty also published a consensus statement arguing that AIDS care and prevention needed to be integrated in the settings hardest hit by the disease.7
A year later, with the help of Sachs and many others, including heroic AIDS activists, the Global Fund to Fight AIDS, Tuberculosis, and Malaria was born. One of the Global Fund’s first major grants went towards AIDS programs in Haiti. That same year, a group of physicians lobbied the new U.S. administration to pursue the same agenda, and before long, George W. Bush launched the U.S. President’s Emergency Plan for AIDS Relief. Together, these two programs brought billions of dollars to bear on the neglected diseases of the poor, and saved—no exaggeration—millions of lives. We believed that these disease-specific programs could, if designed properly, be used to strengthen health systems generally, as they had done in central Haiti.8 Jim Kim left Harvard for the World Health Organization to pursue this vision—bringing better medical services to the world’s bottom billion—on the level of global policy. (Jim later became president of Dartmouth College and was responsible for Dartmouth’s significant presence in Haiti in the first weeks after the quake.)
It was during these years, when I was shuttling between Haiti and Harvard, that President Clinton launched the Clinton Health Access Initiative (CHAI) and became another mentor and colleague. At an AIDS meeting in Barcelona in the summer of 2002, he made plans to come to Haiti and encouraged us to work in Rwanda. “You watch,” he predicted then, “Rwanda will become a model of smart development.” Shortly thereafter, Ira Magaziner, the other driving force behind CHAI, also visited AIDS patients—many of whom had to all intents and purposes risen from the dead after receiving the right treatment—and facilities in central Haiti.
By 2003, when President Clinton arrived to announce his foundation’s intention to help out in Haiti, we were ready to extend our work throughout the center of the country. Indeed, we’d already started and had a crackerjack Haitian team led by Fernet Léandre, Maxi Raymonwille, Loune Viaud, and many others. It was about that time that Louise Ivers, David Walton, Evan Lyon, and Joia Mukherjee, introduced earlier, joined the Haiti team to scale up our efforts within the public sector health system. With support from the Global Fund, we designed our effort to help not only AIDS patients but all patients, and to focus on prevention at the same time. The idea was to work in public facilities (such as the General Hospital, which is where Clinton made his announcement), rather than competing with or supplanting them. The Haitian government was squarely behind the plan. I was as enthusiastic as I’d ever been about linking direct service to training (at Harvard and in Haiti) and research that might inform health policy.
We’d also launched, with Cuban colleagues and the Aristide Foundation, a new medical school that would focus on improving the health of the Haitian poor, especially in rural areas.9 (The great majority of Haiti’s health professionals worked in Port-au-Prince.) We were set for a good decade, I thought, and so did our students and trainees at Brigham and Women’s Hospital (the Harvard hospital where I trained and where we’d launched training programs for young doctors committed to global health).
But then came the February 2004 coup in Haiti, which further weakened the public health infrastructure.10 Haiti’s president and his wife, our staunchest advocates in the fight against AIDS, were spirited away to the Central African Republic in a way that resembled nothing so much as the “extraordinary renditions” of suspected terrorists described in the popular press. Haiti’s elected government was replaced by a group of unelected officials (unelected by Haitians, in any case), and the Prime Minister, Yvon Neptune, was tossed in jail without charges. It was a dispiriting time, in large part because of the lies and distortions that figured prominently in many official policies, including some of my own country.
Although the Global Fund efforts went forward, the Clinton Foundation declined to work in Haiti under the régime installed after the coup (an honorable gesture, which made absolutely no impression on the de factos, as they were called). Instead, the Clinton Foundation urged Partners In Health to launch a major rural health initiative in Rwanda with the national government’s health authorities. I’d visited Rwanda before and admired its governance, born of horrible circumstances and still subject, at the time, to legitimate critique and negative propaganda (some of which came from France, some from surviving architects of the 1994 genocide, but also some from more credible voices in human rights circles). In the fall of 2004, we made a long-term commitment to begin a comprehensive rural health initiative in Rwanda.
From 2005 on, we continued to expand our work in the public hospitals across central Haiti, while some of us, including leadership from our Haiti team and Harvard Brigham colleagues, began setting up shop in southeastern Rwanda. We were first dispatched to a longabandoned hospital in an area of former national parklands where as many as 60 percent of the population had been displaced, at one point or another.
It was satisfying work. By the summer of 2008, it was easy to see the power of good public health governance when linked to funding and to decent implementation capacity. Working with the Rwandan Ministry of Health (which had also received support from the Global Fund) and the Clinton Foundation, Partners In Health recruited and trained two thousand health workers, rehabbed a dozen clinics, rebuilt two hospitals, and broke ground on a third. (We’d been sent to three of the four districts in Rwanda that lacked any working district hospital; the country has thirty districts.) If the work remained on track, we would soon be serving as large a population in Rwanda as we served in Haiti, where the effort had taken two decades.
But Haiti exerted a hold over us all, and we felt it more sharply in times of trouble. The country had known plenty of troubles, even compared to Rwanda, and the situation was about to get worse. During these years, I flew between Haiti, Harvard, and Rwanda, and my family moved to Rwanda’s famously spotless capital city of Kigali in 2006. Kigali was in many ways the mirror opposite of Port-au-Prince. Although Haiti’s capital in 2007 was no longer being termed “the kidnapping capital of the world,” as it had the year before, progress there was slow.11 Haiti was disheveled and disorderly and unsafe. The de facto government had been replaced by one led by René Préval, Aristide’s former prime minister, but his government
was unable to find firm footing. In April 2008, a worldwide spike in food prices (which had almost nothing to do with Haitian policies and more to do with biofuels and U.S. and European agricultural subsidies) led to riots throughout Haiti; attacks on UN peacekeepers stationed there resulted in several deaths, most of them Haitian. Yet another government collapsed, and for months the country had no prime minister because the Haitian parliament refused to ratify the proposed successor, Michèle Pierre-Louis, an economist who had worked on education initiatives and headed up George Soros’s foundation in Haiti.
The riots and political impasse had shaken the eight-thousand-strong UN establishment in Haiti. Leadership in the local UN offices and in New York pushed for a shift of focus, from peacekeeping and policing to what some called “human security”—decent jobs, food security, education, access to clean water, and medical care. From Rwanda, where we’d experienced the effect of that country’s commitment to development and human security, we cheered this shift.
Late August of 2008 found many of us in Rwanda, when, during a visit from President Clinton for the groundbreaking of a new hospital, we got more bad news from Haiti. Another hurricane (on the heels of two before it) had struck northwest Haiti and Cuba with great loss of life in Haiti (but almost none in Cuba, which had evacuated more than a million citizens from harm’s way).12 Haiti’s third largest city, Gonaïves, was under several feet of water. I headed back there and, on September 6, hours after returning from the drowned city, drafted a letter to our supporters. I’ll quote it at length because the sentiment that “Partners In Health is not a relief organization, but we’ll do whatever we can to help” would prove relevant again only fifteen months later. So too would our understanding of the sharp limitations on Haitian officials who lacked the resources to respond to such circumstances. Here is the letter as it was posted:I am writing from Mirebalais, the place where our organization was born, having just returned from Gonaïves—perhaps the city hit hardest by Hurricane Hanna, which, hard on the heels of Fay and Gustav, drenched the deforested mountains of Haiti and led to massive flooding and mudslides in northern and central Haiti. A friend of mine said this morning: “I am 61 years old, born and raised in Hinche. I have never seen it under water.” Gonaïves, with 300,000 souls, is in far worse shape, as you’ll see from the other pictures I append. The floodwaters in Hinche are dropping, but as of 5 P.M. last night, when we left Gonaïves, the city was still under water. And hurricanes Ike and Josephine are heading this way as I write.
Everyone copied on this note has already heard, most probably directly from PIH, about these storms and their impact on Haiti. I apologize for writing again and for asking my own colleagues and friends to consider sending more resources—we need food, water, clothes, and, especially, cash (which can be converted into all of the above)—so that Zanmi Lasante, and thus all of us, can do our part to save lives and preserve human dignity.
The need is of course enormous. After twenty-five years spent working in Haiti and having grown up in Florida, I can honestly say that I have never seen anything as painful as what I just witnessed in Gonaïves—except in that very same city, four years ago. Again, you know that 2004 was an especially brutal year, and those who work with Partners In Health know why: the coup in Haiti and what would become Hurricane Jeanne. Everyone knows that Katrina killed 1,500 in New Orleans and on the Gulf Coast, but very few outside of our circles know that what was then Tropical Storm Jeanne, which did not even make landfall in Haiti, killed an estimated 2,000 in Gonaïves alone....
We’re faced with another round of death and obliteration. Haiti’s naked mountains promise many more unnatural disasters. We know that a massive reforestation program and public works to keep cities safer are what’s needed in the medium and long term. But there’s a lot we can do in the short term to help out with disaster relief.
None of us regard Partners In Health as a disaster-relief organization. Together, we’ve built Partners In Health—meaning the network of locally directed organizations working in ten countries—to serve a different cause. We wanted to attack poverty and inequality and bring the fruits of modernity—health care, education, et cetera—to people marginalized by adverse social forces. It seemed likely, as reports came in this week, that many other institutions and organizations would be far better able to respond to the aftereffects of storms and floods. I’d been told, as the American Airlines flight passed over flooded Gonaïves, that the city was cut off from outside help, but even as I heard this, I knew that our own colleagues were there, volunteering what meager resources we had on hand, and a few hours later I was there, too. I was hoping that we’d find that the city was receiving the expert attention of organizations trained to do disaster relief. So imagine my surprise, yesterday, when I discovered that very little in the way of help had reached Gonaïves or the other flooded towns along the coast.
Although it’s not true that Gonaïves cannot be reached by vehicle, it is true that the city center is still under water, and that the road into the city is well and truly flooded. Between Pont Sondé—the only way to the coast (since the major bridge between Port-au-Prince and Gonaïves is out, as is that to the north)—and the flooded city, we saw not a single first-aid station or proper temporary shelter. We saw, rather, people stranded on the tops of their houses or wading through waist-deep water; we saw thousands in an on-foot exodus south towards Saint-Marc.
We saw a couple of UN tanks rolling through the muddy water over these streets, some Cuban doctors, and two Red Cross vehicles (one of them stuck in mud at least 10 miles from the city), and heard and saw helicopters overhead. But for the most part the streets were full of debris, upside-down vehicles, and dazed residents looking to get out before the next rains. Our friend Deo from Burundi was there and said it reminded him of nothing so much as what he’d seen there, and in Rwanda, at the time of the genocide in 1994—long lines of people carrying little more than their children, goats, and balancing sodden bags and suitcases on their heads.
A speedy, determined relief effort could save the lives of tens of thousands of Haitians in Gonaïves and all along the flooded coast. The people of that city and others have been stranded without food or water or shelter for three days and it’s simply not true that they cannot be reached. When I called to say as much to friends working with the U.S. government and with disaster-relief organizations based in Port-au-Prince, it became clear that, as of yesterday, there’s not a lot of accurate information leaving Gonaïves, although estimates of hundreds of deaths are not hyperbolic. We had no cell phone coverage there and had to wait until last night to call people in Port-au-Prince. One sympathetic American friend, following up on our distress calls about a lack of relief, told me this morning the retort she’d heard from an expert employed by a UN-affiliated health organization: “Three days without water is nothing. People in southern Haiti affected by Gustav went ten days without water.”
No human can go ten days without water. Food, perhaps. But not water. So we can expect that the people you see in these photographs, which I took by borrowing the digital camera of a Zanmi Lasante employee from Gonaïves (whose family, like all those you see, lost everything), are at great risk of falling ill with water-borne illnesses. There is also a lot of dead livestock floating down the streets of the city. The stench is overwhelming.
We are familiar with a lot of the Haitian officials charged with responding to this tragedy, which is, agreed, widespread. They showed up in Gonaïves: the district health commissioner, who is from the city and felt lucky to have avoided drowning; the coordinator of the government’s disaster response; nurses and doctors we’ve known over the years. They are doing the best they can with scant supplies. They are tired, thirsty themselves, hoarse-throated. Even Haiti’s newly appointed Prime Minister, on her first day on the job, showed up this morning in Mirebalais, keeping a promise she made many months ago, long before she was directly involved in politics. She now has to install a new government, perhaps this afternoon,
and respond to multiple disasters at once. These people, who are trying to help their fellow Haitians, deserve our help.13
I wrote this letter a few hours before Ike, the fourth storm, hit Haiti. Pierre-Louis’ first official visit was to the shabby Mirebalais hospital, which sat in a place everyone called lòt bò latem—“on the other side of the river.” The bridge connecting the town center to the hospital was also the span that connected central Haiti to the coast. A modest bit of infrastructure, the bridge was nonetheless a key artery. (Although there’s no reason that the new prime minister would pause to make such an observation any more than might any of those accustomed to crossing it.) But that night, as Hurricane Ike drenched central Haiti’s deforested mountains, a flash flood hit a UN base (home to a battalion of Nepalese peacekeepers) and swept scores of empty cargo containers into the river. The containers—with “UN” marked in huge black letters—struck the Mirebalais bridge with enough force to bring it down, and the Central Plateau was cut off from the coast for months. The only way to reach the hospital was in dugout canoes.
This letter became Partners In Health’s first online appeal. (The generous response to this letter would later be dwarfed by the heartening response to our appeals after the earthquake.) After returning to Harvard, I forwarded the Gonaïves letter to a number of current and former U.S. government officials. We heard back from several of them, including President Clinton, who called within hours of receiving the appeal. He underlined the need to link palliation of suffering—disaster relief—with strategy and longer-term investments to grow Haiti’s economy. To paraphrase his comments: “What can I do to help? We have to provide relief, but we need to focus on the big picture: Haitians need more and better jobs, and perhaps some of them could be in reforestation and public works, like during the American Depression.” Clinton called as I was about to begin a lecture at Harvard Medical School, and I thought, once again, about how disparate were the worlds we spanned: Haiti and Harvard, New York and rural Rwanda.