Haiti After the Earthquake
Page 12
Régine and her bandmates had been loyal supporters of Partners In Health for a number of years. After traveling to Haiti together after the storms of 2008, they pledged a substantial fraction of their concert and album earnings to our work. They were also about to launch, along with fellow Haitian-Canadian Dominique Anglade (who lost both of her parents, the Georges and Mireille mentioned in Régine’s essay, in the quake), an NGO that would offer poor families in central Haiti access to credit and basic services such as health care and primary education.26 After the ministerial meeting, it was good to discuss grassroots efforts—even though we knew them to be necessary and worthy and still insufficient after the quake. Reconstruction would require billions of dollars and a new way of deploying them in Haiti. That’s why my next stop was Washington, D.C., where I was scheduled to address the Senate Foreign Relations Committee.
Régine drove me to the Montréal airport the next day. Having spent the morning preparing remarks for the Senate, I bought a few magazines and papers to read en route to Dulles. Each of them featured Haiti on the cover. One of the dailies ran a story about a young Canadian man who, wanting to help out in Haiti, flew to the Dominican Republic and drove west to Port-au-Prince without much in the way of cash—or anything other than his goodwill. Before long, he ran out of money, and the Canadian embassy had to help send him home. It was meant as a lesson about the importance of planning and the shortcomings of goodwill alone.27 But it could stand as a parable for foreign aid, except that not all aid has been as honorable in intent. That would be a point to make diplomatically in the Senate hearing.
I met a colleague, Cassia Holstein (who later agreed to help co-edit this book along with Abbey Gardner), at Dulles, where we sat in a coffee shop and watched the State of the Union. President Obama moved through a list of domestic grievances, as was his job, but we were pretty certain he’d turn soon to Haiti. (Ophelia Dahl had been invited to the formalities by the Speaker of the House.) A crowd of airport staff, many of them émigrés from disrupted regions in the Horn of Africa, had also gathered to listen to the President’s remarks. It was hard not to wonder if humanitarian aid and development strategies and donor conferences had helped much in their corner of the world. Scanning the coffee shop filled with people displaced by forces beyond their control, I wondered how often their thoughts turned back to distant cities and villages.
Obama did indeed bring up the earthquake. He reaffirmed the United States’ commitment to help Haiti: “As we have for over sixty years, America takes these actions because our destiny is connected to those beyond our shores. But we also do it because it is right. That’s why, as we meet here tonight, over ten thousand Americans are working with many nations to help the people of Haiti recover and rebuild.”28 Ten thousand Americans, and probably as many more from other countries (there were almost a thousand in the Cuban medical brigade alone)—it was easy to forget just how substantial the relief effort had been.
But it was important also to make sure that the purveyors of relief added up to at least the sum of our parts. That’s why we were headed to the Senate Foreign Relations Committee. It wasn’t the first time I’d testified there. In 2003, I’d called for an end to the de facto sanctions of development aid to the government of Haiti.29 At the time, influential American institutions were effectively blocking four loans to Haiti from the Inter-American Development Bank—for primary health care, education, potable water, and road improvement—because they didn’t condone the outcome of Haiti’s 2000 elections, which brought left-leaning Aristide back to power. At least, that’s what I believed. 30 The stated reason for our unstated freeze of assistance to the Haitian government was dissatisfaction with the process of parliamentary elections.
Political views aside, any doctor working in Haiti during these years had reason to object to manipulation of development assistance that slowed credit approval for major water and health care projects. The Haitian government, with a national budget smaller than that of a single Harvard teaching hospital, could not clean up water supplies or revitalize its health system without access to credit. Although our own work was independent of such aid, we were tired of seeing waterborne diseases and other easily preventable conditions afflict our patients. A few years passed before we got wind of this state of affairs and started writing op-eds (one of them with Jeff Sachs, who was equally appalled31). The loans were still blocked at the time of the 2003 hearing; my testimony made it crystal clear that I viewed the situation as little more than manipulation of development assistance for political reasons. It took all the guts I had to make these points in Washington.
I’d also made a more general point in my 2003 testimony: it wasn’t a good idea to funnel foreign assistance exclusively through NGOs and private contractors. Without real and sustained commitments to strengthening the public sector—including its capacity to monitor and coordinate services offered by NGOs—who would make sure development funds were being used efficiently? During the same years as the aid embargo, international trade policies cut Haitian farmers off at the knees, accelerating vicious cycles of urban migration and deforestation. These twin epidemics of urbanization and ecological decline set the stage for food insecurity, vulnerability to heavy rains and storms, massive overcrowding, and shoddy construction in Port-au-Prince. (The quake would, of course, reveal the anatomy of such weaknesses in high relief.) I hadn’t seen much point in mincing words. Although my 2003 comments were met with civility, I wondered if such candor were the best way to unfreeze the development projects (the reason I had come). I wasn’t sure I’d be invited back.
This time, in 2010, the invitation had come from Senator John Kerry, the father of one of my medical protégées and coworkers. He would be chairing the hearing. I knew Kerry cared about Haiti, and he set the tone for the session: ″The task before us remains far from over.... We need to use this humanitarian crisis to begin reversing the poverty and human degradation that plagued Haiti before this catastrophe.... We need to help Haitians build a sustainable foundation—physical, social, economic—for a stronger and more stable society. This is a chance for Haitians to reimagine their country as they rebuild it.”32
As any fan of Haitian art knew, the Haitian imagination was rife with utopian visions. And even more were emerging after the quake. Rebuilding would require new vision to move away from a system of foreign assistance that rewarded private contractors richly even when outcomes were not those promised or desired. It was my goal that day to be critical and constructive about humanitarian aid—to reassure the committee that relief efforts to date had saved lives and assuaged suffering (and truly they did both) but also to suggest that Haitians would need a different kind of development assistance to build back better. A new set of ground rules for foreign aid was needed. Saying all this in front of the Senate felt like walking a tightrope. One way to broach the subject was to focus on the shift from relief to reconstruction, which everyone agreed was necessary.
This transition was upon us even two weeks after the quake. Ongoing relief efforts, focused on addressing the initial wave of devastation after the earthquake, were turning to a new set of concerns. Building safe schools and safe hospitals, even makeshift ones, were obvious needs, and installing storm-resistant housing was a priority with the rainy season approaching. Likewise, the planting season demanded fertilizer, seeds, and tools. Hastily cobbled together camps—Port-au-Prince alone had hundreds of them—were at risk of outbreaks of cholera and other waterborne diseases; camp residents needed more tents, tarpaulins, and latrines (or composting toilets). The Haitian government had hoped to avoid huge camps, which are difficult to manage, but these were precisely what came to fill every open space in the capital. In my 2010 testimony, I told those gathered in the Senate Office Building how humbling it was to see ambitious recovery efforts move slowly, in large part because of delivery challenges that predated the quake. Recovery faced acute-on-chronic problems.
If past were prologue, Haitians themselves would be blamed
if such problems were not addressed. But many factors, within Haitian borders and without, had weakened Haiti’s institutions and made its people so vulnerable to the quake. The foreign aid apparatus, for one, kept too much overhead for its operations and relied too heavily on international NGOs and contractors. This was another acute-on-chronic problem. Even before the quake, there were more NGOs per capita in Haiti than in any other country around the world, save India. The “Republic of NGOs” came about in part out of need (the government certainly could not provide adequate services for its citizens) but also because of U.S. laws, including the Foreign Assistance Act of 1961 ″and later revisions,” which prevented direct investment in the public sector.33 It was an outmoded way of doing business, I argued. Post-quake Haiti needed many of the foreign contractors and NGOs because its implementation capacity had long been weakened. But Haiti also needed new approaches to foreign assistance that might create good jobs for Haitians and reduce Haiti’s dependence on aid.
In Washington, where attention spans are short, it also seemed prudent to remind those present that, over the past three decades, U.S. aid policies had seesawed between the permissive and the punitive. Neither the international community nor the United States had provided credible, long-term, financial investment in Haiti. We needed to revisit these policies. Forgiving Haiti’s crippling debts was an easy place to start.34
This argument would have been out of place in the quake zone, where the daily business of survival reigned. But as recovery followed relief, we needed to think beyond mere survival and about job creation, local business development, watershed protection, alternative energies, and access to quality health care and education. Goals such as these could orient strategic choices for the self-described friends of Haiti. For example, cash transfers to women, who hold the purse strings in many Haitian families, would have a significant and salutary effect, as would investments in girls’ education.35
My chief point that day echoed Senator Kerry’s: the quake offered a chance to do reconstruction right. We needed to construct hurricane-resistant houses, build communities around clean water sources, and reforest the terrain to protect from erosion and to nurture the fertility of the land. Above all, the quake offered a chance to push job creation as a recovery strategy. It was a strange irony, I noted, that supporters of economic assistance to Haiti were then obliged to shill for “cash for work” programs—the quaint notion that people should be paid for their labor. It was absurd to argue that voluntarism and food-for-work programs would create sustainable jobs or meaningful development. With more just ground rules, the process of reconstruction itself could stimulate enough jobs to help get the Haitian economy back on its feet.
That, in any case, was my argument and conclusion: “If even half of the pledges made in Montréal or other such meetings are linked tightly to local job creation, it is possible to imagine a Haiti building back better with fewer of the social tensions that inevitably arise as half a million homeless people are integrated into new communities.”36
In spite of its errors—no formal pledges had been made in Montréal, except the pledge to meet again at the end of March—the testimony was well received, which was a relief. But beyond relief, my strongest sentiment was déjà-vu: I’d made many of these same points in the same room less than seven years before.
Such testimony becomes part of the public record, so I later looked up my 2003 remarks. One of the conclusions was eerily familiar: “Haiti needs and deserves a Marshall Plan.” Also from 2003: “Rebuilding Haiti will require resources. The Haitians have a saying: you can’t get blood from a rock. Massive amounts of capital need to flow into Haiti in order to stay the humanitarian crises I’ve described. But this capital cannot go only to groups like ours—to NGOs or ‘faithbased organizations.’ We’re proud of our work in central Haiti, but that’s where we live and work: in a circumscribed bit of central Haiti. Only the Haitian government has both national reach and a mandate to serve the Haitian poor.”37 These repetitions are underlined here not to suggest some prescience or consistency, but rather to highlight the persistent pathology of inaction—or worse—spanning previous decades of development assistance and foreign aid to Haiti.
The presentations were scripted, but exchanges with senators and the global peanut gallery (such hearings are broadcast live on C-SPAN) were not. After the two other presenters (James Dobbins of the RAND Corporation and Dr. Rony François, former Secretary of Florida’s Department of Health) had delivered their remarks, Senator Kerry guided the discussion. He first asked about food shortages. In the short term, it was hard to think of an alternative to the World Food Program’s logistically robust food distributions. But almost none of the food it procured was locally grown. I was proud to be able to offer an example of local production: vitamin-enriched peanut butter had proven a miraculous treatment for childhood malnutrition while also creating jobs and stimulating local agriculture (simply by purchasing locally grown peanuts). It wasn’t nuclear physics. Such investments could help diminish hunger, support local farmers, and build food-processing capacity in rural Haiti.38
Senator Ben Cardin of Maryland asked an important question: How might we learn from past mistakes in aid delivery? Most of those present wanted to correct the inefficiencies in the aid system. People in the audience, seated behind me, passed notes to me in the hopes that I might underscore important points. One such note was affixed to a news report from that morning, which announced that the Haitian government had received significantly less than 1 percent of U.S. relief aid since the quake.39 Later we would learn that it was not only U.S. aid that bypassed the government: an estimated 0.3 percent of all Haitian quake relief went to the public sector.40 In fact, more went to the government of the Dominican Republic than to Haiti’s government. The lion’s share of every U.S. dollar spent on earthquake relief went to the U.S. military’s efforts, which included search and rescue and logistic support needed, as we had learned, to save lives.41 But the military leadership we’d met in Haiti would be the first to say that relief is not the same as recovery.
Although it wasn’t clear how best to make the leap from relief to recovery, I returned to Haiti torn between optimism (the goodwill in Montréal and in Washington felt real) and pessimism (we’d been saying the same things for well over a decade). One thing was certain: there was little knowledge, in Washington, of Haitian history or of the close links between the two oldest republics in the hemisphere. Most Haitians I’ve met argue that it’s impossible to know the history of either country without knowing that of the other.42 But the powerful could afford not to know.
I hoped that a new infrastructure of transparency might grease the aid machinery’s skids and improve performance on all sides. Colleagues in our tiny UN office were already tracking aid pledges and publishing disbursement rates (mostly shortfalls) online. It was our shared hope that this platform—the infrastructure in question—would help Haiti build back better and move us beyond rudimentary declarations of support to a focus on delivery. Otherwise, why have meetings a thousand miles away from those needing water, sanitation, medical care, solid homes, and decent jobs?
These were the questions on my mind when I headed back to Haiti after the Montréal meeting and the Senate testimony. Thirty days after the quake, we were once again preparing to receive President Clinton, who was coaching us on the transition to reconstruction. Claire Pierre had been working closely with the Minister of Health, Dr. Alex Larsen, who encouraged us to focus on rebuilding health infrastructure. In one meeting, he asked us to rethink the hospital we’d been planning to build in Mirebalais since before the quake. “You need to set your sights higher,” he said. “The hospital needs to be a place that can train young doctors and nurses, but also one that can train allied health professionals—the people who run labs and pharmacies—and community health workers. It needs to be bigger, many times bigger, than what we agreed upon.” He planned to say as much to President Clinton, who would return to Haiti on February
11.
We were working with Clinton’s team and the Office of the Special Envoy to plan this next visit. I suggested that Clinton should visit the Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), a Cornell-affiliated NGO led by Dr. Bill Pape. Pape had been one of four physicians invited to the White House when, in 2003, the Bush administration contemplated the launch of its AIDS program. (The President’s Emergency Plan for AIDS Relief, or PEPFAR, as it would be called, would prove to be the most ambitious global health program of the preceding decade.) I was there too, and had worked with Pape for almost twenty-five years. After the quake, he also began pressing me to focus on the health sector—not because we were physicians but because improving access to health care was, like improving education and sanitation, something everyone could agree on.