by Paul Farmer
Clinton helped work through these disparate fears and concerns, approving projects that fit the national plan and bringing into the open who was doing what and with how much money, as we had tried to do in the Office of the Special Envoy. Staff and space and resources didn’t show up until June, when Norway and Brazil sent $45 million and Mexican and Canadian philanthropists provided another $20 million in business loans. The Clinton Foundation chipped in $1 million to build urgently needed storm shelters in areas particularly vulnerable to hurricanes or heavy rains.14
A system of financial tracking and aid coordination that would build public-sector capacity seemed like a good idea. The Haitian government had tried to coordinate aid and NGOs in the past but with scant resources and personnel. (The two members of the NGO coordination unit had perished in the quake.) The UN cluster system was still struggling to keep track of all the groups working in post-quake Haiti. The Ministry we knew best, Health, lacked even the space and staff to vet offers of help—some great ideas, some goofy ones—that came in over the transom, if they’d still had a transom.
There had to be better ways to speed up implementation; money was clearly out there. In addition to the promises from officialdom, Haiti was also the object of a tsunami of generosity: it was estimated that 50 percent of American households donated to earthquake relief. 15 And families across Europe, including the U.K. and generous Ireland, responded with significant sums, too. Just as no previous natural disaster had wreaked such havoc in such a crowded space, neither had one prompted such an outpouring of solidarity. Where lay the disconnect between the great need on the one hand and the steady flow of aid and support on the other?16 What would it take to transform these immediate expressions of solidarity or mercy or pity into the desired long-lasting outcomes—safe housing, clean water, good schools, health care, food security, and the dignity that comes from being liberated from the noxious cycle some describe as underdevelopment and others as structured dependence?17
One unanswered question was how much it would take to rebuild Port-au-Prince. The $9.9 billion pledged to Haiti in New York represented about $1,000 for every Haitian—not a lot if you’re trying to rebuild a business or home, much less a safer capital city. And what if only 15 percent of the funds pledged arrived, as had occurred after the 2009 donors’ conference? What little euphoria we felt right after the pledging conference gave way to anxiety and discord all too soon.
It was urgent that reconstruction start boldly and visibly. How would more than a million refugees make do in the spontaneous settlements throughout urban Haiti? We knew to expect strong winds and driving rain by mid-April, which threatened to strip the displaced of their tarps and tents and sheets, leaving the Haitians standing—if they still had strength to stand—on acres of mud and waste. People in the camps, some of them perched on steep hills, dreaded the rainy season and the flooding and mudslides that came with it. Every heavy rain that summer triggered anxiety and endless calls among groups seeking to provide care in the settlements. It proved far easier to demand better coordinated assistance, as John Holmes had done in February, than to really make it happen.
The coming rains also signaled the beginning of the planting season. The post-quake exodus from Port-au-Prince had placed great strain on rural host families, who had long struggled with food insecurity. They needed to turn their attention again to agriculture so that Haiti would not rely on imports for basic nutrition.
Back-to-school season was a sorry time. Many children in Port-au-Prince, especially those living in the camps, had nowhere to go; their schools had been damaged and many of their teachers killed in the quake. Schools needed to be rebuilt and temporary solutions were needed to keep children off the street and out of gangs. Before the quake, demographers and aid agencies spoke of the “youth tsunami” about to wash over Haiti, as if Haitian youth were more a threat than asset.18 Human capital had long been Haiti’s chief asset, and getting children and young people into safe schools that offered modern pedagogy was a top priority.
We spoke often of building back better, but what did it really mean? Literally, of course, it meant building disaster-resistant homes and other structures. It meant rendering the infrastructure of Port-au-Prince capable of supporting the millions of people who lived there. It meant building roads and bridges, improving water and sewage systems, and repairing old hospitals and building new ones. It meant making sure schools didn’t suddenly collapse and mudslides didn’t take down hillsides covered with houses. All these desired outcomes could mean creating jobs in the short term, and some of us felt that the most urgent task of all was the creation of jobs that would confer dignity to those in greatest need. With well-paid jobs, Haitians would themselves put safer roofs over their heads.
But only a minority of those displaced after January 12 would end up with more than plastic or canvas over their heads. By early summer, well over a million people were still living cheek-by-jowl in the camps, and moving people into safer housing was again declared a priority. Many Haitians were already patching up homes on their own. Haiti’s government and the shelter experts had announced resettlement strategies by the dozen, but as usual, more design and planning occurred than implementation.
One project that attracted attention was a large resettlement complex proposed for Corail-Cesselesse, a windswept plain to the north of Port-au-Prince. This seemed an odd location because the region boasted little more than a few spindly trees. But we were eager to see people leave the muddy urban camps, and one of the most credible reporters living in Haiti had spoken of the project in fairly glowing terms: “The organized relocation camp at Corail-Cesselesse,” he commented, “has thousands of spacious, hurricane-resistant tents on groomed, graded mountain soil.... Camp Corail offers a glimpse at what relief efforts can achieve; sturdy tents, adequate food, sanitation, and security.”19 Corail, we read, would be transformed from a model camp into a planned community with three hundred thousand spacious homes, restaurants, stores, and garment factories. Some began calling it a “Zen city,” and “the key industrial city of the Caribbean.”20 Such hopes triggered a charrette of feverish planmaking and site design.
The promise of construction jobs lured thousands to the deforested plain of Corail to stake out a claim in this promising frontier settlement. But by July, the building process—the business of implementation—had stalled. Some disagreed about where to start construction; others about the right contractors for the job. Of the many planners, architects, potential builders, and engineers involved in the project, few seemed to be talking to one another. I asked one of them why the project was stalled, and he blamed the lack of clear title, an inept bureaucracy, fractious contractors, and a touch of sabotage. Then summer rains revealed the area as an immense floodplain; the proposed buildings would sink in the mud.21 Corail was canceled. Many other resettlement initiatives lost steam as well, even as the rains continued to fall.
More modest efforts were easier to pull off, which is perhaps one reason why nimble NGOs seemed to thrive in Haiti. Although few displaced by the quake had the good fortune to end up under a real roof, among them were the more than fifty unaccompanied minors we’d come across in the General Hospital. Loune Viaud had been looking after them since the quake. With help from my Pétionville host Maryse, Loune sealed the deal on a property in northern Port-au-Prince, on the fringe of the quake zone. She hired health aides and rehab workers, mostly women rendered expert by their own experience as mothers, who were coached by professional physical therapists from Miami, Israel, and the Zanmi Lasante team. (Most of the children had severe disabilities.)
The place soon became a veritable oasis: a house full of kids and nurses surrounded by a few acres of well-tended land, lush with mangos and other fruit trees. It had a temporary library, a pool, and a humble fountain, which had been drained when they found the place but now flowed quietly. Chickens and guinea pigs were penned up around the periphery, and a tilapia hatchery and hydroponic gardens were being added in th
e backyard. Dozens of construction workers—there each time I visited, usually on weekends—were also putting up a large staff dormitory. The place was christened Zanmi Beni—“Blessed Friends”—and became an oasis both for the children and for a handful of displaced health professionals and volunteers.22
Three medical students, left homeless and school-less by the quake, were also living there in tents. For the first time in almost a century, the national medical and nursing schools would have no graduates. Although one class was receiving training in Cuba, few young health professionals would be entering service in the coming years. My colleagues at Harvard, Partners In Health, and Zanmi Lasante were trying to help fill this gap, including the Minister of Health’s request that we triple the size of the Mirebalais hospital. The Mirebalais expansion was already taking root, thanks to the hard work of volunteers in Chicago, Boston, and across central Haiti.
The medical students at Zanmi Beni reminded me of three Haitian medical students I’d met on that first night back in the darkened General Hospital. They hadn’t eaten much since the quake, had lost their homes, and were there trying to help out at the hospital. But the only question they asked was: “How can we continue our medical studies?” Here was another role for American universities: to make sure that the current generation of trainees—in medicine and dentistry, nursing, pharmacy, and all the allied health professions—had a chance to complete their training. After Katrina, Harvard and other universities had taken students from Tulane, Dillard, Xavier, and the University of New Orleans, and now we need to help students from Haiti, too. Jim Kim, the President of Dartmouth, was up for it. At the Harvard Medical School Dubai Center, half a world away, health providers were being trained with the same methodologies we used in Boston. The goal was to realize the same standard of pedagogy and care at the two institutions. Most American research universities undertook similar “twinning” efforts in China, Singapore, and elsewhere in Eastern Europe and Asia and Latin America. But these sorts of collaborations were rare or weak in the poorer reaches of the world. The teaching hospital we were planning in Mirebalais would offer another home and a center of excellence, we hoped, for the next cohort of Haitian health professionals.
If we could build a major teaching hospital in the middle of central Haiti, seek the blessing of the Interim Haiti Recovery Commission, bring in new partners, and use private capital, we could help strengthen public health and medical care and medical education all at the same time. It was possible to imagine making a significant contribution to reconstruction, which was a lot more appealing than complaining about its glacial place and bemoaning failure.
I had personal reasons for wanting to work in Mirebalais, too. It was my first home in Haiti, where I’d first met Mamito and Fritz Lafontant. The summer of frustration, 2010, opened with a personal loss: Mamito died in June from a stroke. Mamito had taught me a lot over the previous twenty-seven years. She liked to give instructions, but her versions of “wipe your feet” or “clean up your room” were broader in scope, if equally to the point: “Make this house waterproof for this family; put tin on the roof and cement on the floor.” She issued more typical maternal fiats as well, and everyone who visited Cange got a little dose of Mamito’s mothering.
During the months after the quake, Mamito and her close-knit team received medical volunteers from all over and thousands of patients. She spent her days between the hospital and the church, which had remained an ersatz trauma ward for months. Well or unwell, she rose every day to give instructions to the planefuls of doctors and nurses and physical therapists who arrived in Cange. Mamito’s job was to mother them a bit too: to make sure they ate enough and had clean scrubs and got a little rest now and then.
Her passing left a huge void in my life and the lives of many others. Didi flew back for the funeral, and then we returned to Rwanda for our daughter Catherine’s confirmation. (Our work in Rwanda was going well; we were trying to hasten the completion of a flagship hospital in the northern Burera district.) I needed a break from Haiti and the grueling back and forth to Boston, and my coworkers did, too. The transnational doctors, a hardy lot, were weary—even the indefatigable Claire Pierre seemed tired. I was also falling behind in my Harvard duties and leaning on colleagues there to pick up the slack. But most of all, I wanted to see my kids.
Somewhere on the long list of reasons why the camps kept growing over the summer—the top reason being that the displaced had nowhere else to go—was that some supplies and provisions were reaching the camps, and the situation outside them was dire. By some reports, water insecurity had lessened throughout Haiti because aid groups were providing clean drinking water in the camps. One survey in Port-au-Prince suggested that diarrheal diseases had dropped 12 percent below the pre-earthquake level.23 However, the massive importation of bottled water wasn’t sustainable, and some local bottlers and merchants began urging aid groups to stop distributing free water. But given the lack of sanitation in many settings, the local water supply would be “sustainable” only if it did not become a conduit for waterborne disease.
By mid-July, most involved in quake relief—including officials from USAID, which in previous years had tried to skirt Haitian institutions—understood all too well the need for a new approach to delivering services. After reporting the improved water security in Haiti, Paul Weisenfeld, Haiti Task Team Coordinator for USAID, observed: “I think it’s key to us that if we’re going to have sustainability we are going to have to work through Haitian institutions, which requires strengthening them. Obviously [they’ve] been weakened tremendously by this earthquake, so at the same time that we implement reconstruction programs, we need to strengthen government institutions so that we can work through them.”24 The term “sustainability” has long been abused in development circles. It admits too many meanings. Sustaining lives in these camps would mean sustaining supply lines for as long as people lacked homes and jobs. Otherwise, we would see outbreaks of waterborne disease before the rains ended.
The greatest challenge of economic development in Haiti had always been massive job creation. By summer, more and more agencies were implementing “cash-for-work” programs. Such initiatives were surely one good way to move resources from the self-described donor nations to the survivors who were able-bodied and anxious to work. But the UN reported that these programs had generated only about thirty-five thousand jobs. What was needed was more on the order of five hundred thousand paying jobs, and soon. Haiti needed jobs that would confer dignity on the poor. As FDR said early in the Depression, “The Nation asks for action and action now. Our greatest primary task is to put people to work.”25 Martin Luther King and many others had echoed the view that paid labor confers dignity.26 Most champions of rights for the poor, it seems, had come to this conclusion. A jobs campaign of this magnitude—with a focus on young people, especially young women—would not be a panacea for Haiti, but it would be a step forward on the long road to reconstruction.
While in Rwanda, I thought long and hard about that country’s recovery from the genocide and about other recoveries of recent history. Bold rebuilding plans always include major public works projects. Haiti needed them, too. There were innumerable public-works jobs imaginable, from reforestation and rubble removal to building schools that were safe and well-supplied. Haitians needed a real health system, which would require massive investment in new clinics and hospitals, staff to run them, and health insurance—yes, “the public option.” (Only three hundred thousand families in Haiti had private insurance.) These tasks were indivisible, as FDR noted at the outset of the Depression: “Public health . . . is a responsibility of the state as [is] the duty to promote general welfare. The state educates its children. Why not keep them well?”27
Job creation and improved health and educational services, with greater investment in the public sector, should have been a big part of the recovery plan. The Interim Haiti Recovery Commission needed to be swift and nimble; the rules of the road for development ass
istance needed to be rewritten, not to favor contractors and middlemen and trauma vultures, but to favor the victims of the quake. By summer, shovel-ready projects that could create tens of thousands of jobs (or perhaps more) were available. But most people were living in poverty without reliable jobs. Haiti’s ti machann (“market women”), for example, seldom had access to capital or financial services and had been working against an undertow of unfair trade policies. But they were as entrepreneurial as anyone.
Projects of all sorts could be green-lighted by the recovery commission, but they would move sluggishly if the funds seeped in slowly or if strangling strictures were placed on their disbursal. The commission didn’t even have its own project money. In the face of urgent need, were we well served by the fetishization of process that retarded the flow of capital into the hands of poor families?
Americans with long memories knew it was possible to move forward with a sense of urgency. During the Depression, job creation and improved services—from health care to education to rural electrification—were the focus of great efforts and significant enthusiasm. Roosevelt, then the governor of New York, called for “workfare” and welfare through the Temporary Emergency Relief Administration. This call was made on August 28, 1931, and the program was up and running by winter.28