by Paul Farmer
Later, these lessons were brought to scale through many other programs, including the Civil Works Administration, which created millions of jobs and moved billions of dollars into both the public sector and the hands of the previously unemployed. Many civil works programs—dams, municipal water systems, public power plants, roads, reforestations, communications infrastructure, even blazing the Appalachian Trail—were completed in part because of the Civil Works Administration and other civilian jobs programs.
Certainly Haiti’s need was no less great than that faced by the States during the Depression.29 A better functioning tax base would have been handy. (The Haitian version of the IRS had never functioned well and, like the Ministries of Health and Education, had been destroyed in the quake.) But in principle, other capital was available: the world had responded generously, and now it was incumbent upon us to move these resources into the hands of the Haitian people. It was not a matter of choosing between public and private sectors, but of focusing resource distribution on the poor and displaced by providing basic services and by launching substantial job creation efforts. Only an infectious failure of imagination would slow such projects down or smother them in their cradles.
In Rwanda, I thought about the many meetings I’d attended since the quake. Some were less mind-numbing than others. Meetings involving President Clinton tended to be engaging because he always had good ideas and tried to boost morale. Other meetings seemed promising as well. On June 7, I was the lone American invited to a tripartite health summit between Haiti, Cuba, and Brazil. When I was informed by Claire Pierre that the meeting was to be held in the Hotel Montana, where Walt Ratterman and Mario Pagenel and so many others had died, I thought there had been a mistake. The Montana was down. But Claire would know; her mother had lived in an apartment there, which had been leveled. “Yes,” she said. “That’s where the meetings will be held. Some of the conference rooms under the hotel are intact.”
On top of a hill overlooking the city and the bay and also the Central Plateau, the hotel grounds were an eerie perch. The building was little more than a pile of plaster and concrete and twisted steel. One of the owners limped over toward us. (She had been badly injured, I knew, and had lost one of her grandsons along with most of her guests.) She led us to a lower terrace under which lay, undamaged, a subterranean meeting room. The tripartite mission (Haiti-Cuba-Brazil) would meet there, she said. “And I have something for you,” she told Claire. “Some things I found in the rubble.”
When we emerged for a coffee break (and a break from translating between doctors speaking in French, Creole, Portuguese, and Spanish), the Montana owner gave Claire her sister’s wedding album. “I found this in what used to be your mother’s apartment.” The album was water-stained and warped, but the pictures were mostly undamaged. It was one of the only times that I saw preternaturally cheerful Claire tear up. She hugged the album to her chest. “And for you, doctor,” continued the owner, “I found this.” She handed me a waterlogged report of the health status of the Haitian people. Probably the work of some consultants who had stayed at the Montana, it was still wet and in worse shape than the photo album. I took it gratefully, and we returned downstairs to join the Babel of physicians from across Latin America, as they asked how a proper health system might emerge from the wreckage.
To those in the camps, and to many of my colleagues, the summer was one of lowered expectations. If help was on the way, it was travelling slowly and in the form of discrete projects visible to some but not to all. At least we knew the teaching hospital in Mirebalais—by far the most ambitious project we’d ever taken on—was moving forward. Many others labored mightily to improve conditions in one way or another. But projects without perceived national reach were not cheered by those untouched by them. As the rains fell, weeds appeared and began to cover some of the uncleared rubble. It was a summer of great discontent.
The months passed by in a blur—more meetings, yes, but also a frenetic push to get money and projects moving. It was during that summer that a group of us decided to pull this book together. We hoped it might lend clarity to the debates about reconstruction, and that it might serve as an account, however partial, of those first six months. But to write a book, or even a few chapters, required time alone. I hoped to find such time during a giant AIDS conference in Vienna in the third week of July. These meetings, which took place every two years, gathered twenty thousand people and were quite a spectacle. Although meetinged-out, I’d promised Clinton and some Haitian colleagues, including Dr. Pape and Father Eddy Eustache, that I would be there. Vienna was not a city I knew, but I’d imagined a tranquil week in a leafy city, when half my time could be spent writing. (Cassia Holstein promised to meet me there for this reason.)
We arrived in the middle of a heat wave, hotter than any I’d endured in Haiti or Africa, and there was a good deal less tranquility and writing than hoped for. President Clinton gave the meeting’s plenary address, speaking of Haiti. The net movement, he said, was forward and positive. A few of us gave a presentation about medical care in Haiti after the quake. I was eager to hear Dr. Pape’s opinions and projections. (GHESKIOʹs clinics and labs, which he had founded two decades previously, were smack in the middle of the quake zone.) He predicted that although Haiti’s AIDS epidemic remained “under good control,” the conditions in the camps, including the one abutting GHESKIOʹs downtown campus that we’d visited with Clinton in February, were ripe not only for epidemics of waterborne disease but for a rise in tuberculosis. Some of us, Pape included, remained worried about the introduction of cholera and other pathogens unknown to Haiti—as AIDS had been unknown a few decades before.
As in all such conferences, the most interesting conversations occurred dans les coulisses. Several of us met to discuss the Global Fund’s grants to Haiti. The last real meeting on the topic had started at 4:00 P.M. on January 12, and the problems with the upper-level management of Haiti’s AIDS programs remained largely unaddressed. It was also in Vienna that the Minister of Health in Lesotho, who had once worked with the Clinton Foundation, reiterated a promise to take in some Haitian students at their university. (The Rwandan government had done the same.) Didi agreed to spearhead that effort after her troubling visit to Parc Jean-Marie Vincent earlier that month.
One of my only celebratory breaks that summer was the July 31 wedding of Chelsea Clinton and Marc Mezvinsky. Chelsea and Marc had traveled to Haiti together shortly after the quake, and since then, Chelsea had been back to the camps, including Parc Jean-Marie Vincent. A student of public health, she had warned us of cholera and other waterborne pathogens. But on that day, we raised none of these topics. We tried to avoid saying the words “Haiti” and “earthquake” altogether. (It was a reminder that there might be other topics of conversation.) It was there, in a lovely town in upstate New York, that I finally started working on this book. The day after the wedding, to encourage myself to write—to stop and think and write—I made a brief pilgrimage to the graves of Franklin Delano and Eleanor Roosevelt.
Within a week, the proud father of the bride and I were back in Haiti, where it was almost as hot as the Austrian capital. Clinton arrived in Port-au-Prince on August 5 to help launch the newly baptized Interim Haiti Recovery Commission. As had been the case from the beginning, disagreements about the commission’s role bubbled just under the surface. Some representatives of the development enterprise were resentful—why stand up a body like this, they asked, if there were existing bodies?—but most were worn out and ready to acknowledge that something new was needed. The diplomatic community was also in large part bound by the strictures of that world to at least feign enthusiasm for the commission. The Haitian politicians were, as ever, split—some denouncing the commission as a failure even before it met for the first time and others, including members of the Préval administration, obliged to be supportive. Many of the behind-the-scenes meetings were devoted to making the commission nimble, transparent, and strong without weakening the line mi
nistries (the government agencies in charge of health, education, agriculture, et cetera). By this late date, most NGOs and aid groups allowed that efforts to bypass the line ministries had worsened Haiti’s governance and fueled the overall lack of coordination. But how to repair this error while also speeding up reconstruction?
Claire Pierre was asked to head up the health sector of the commission. Could she be seconded by Harvard (and her hospital) to lead this small team? If anyone had the patience and competence for such a thankless posting, it was Claire. We were in full support, if she was willing to risk it. She was.
The next morning, Clinton traveled to Darbonne Sugar Mill in Léogâne, the town nearest to the epicenter of the quake. The only operational sugar mill in all of Haiti, Darbonne was always in the throes of closure because its output was as meager as its profit. Clinton was investigating whether investments in the mill might generate jobs and help stimulate biofuel production. We also came to see how Léogâne was faring: what had happened to schools and health centers, and what were the conditions like in its spontaneous settlements? I had worked in Léogâne’s hospital as a medical student but had not been back in several years. (Léogâne was also the hometown of Edwidge Danticat, a friend and contributor to this volume.)
Léogâne is close to Port-au-Prince, but it takes hours to get there by road because of traffic south of the city; the road had also been damaged by the quake. Clinton and I were instead flying by Russian helicopter (manned by Ukrainian pilots eager to have their photos taken with him). The view from above was still difficult to bear. Seven months after the quake, less than 2 percent of the rubble had been removed from Port-au-Prince and the surrounding areas.30 The heavy machinery needed to crush and clear rubble was in short supply. During most of the twenty-minute flight, there was not a glimpse of green. But the southern sprawl of Port-au-Prince gave way to farmland as we neared the temblor’s epicenter.
Even in the farmland, many concrete buildings had collapsed, and from the chopper, pancaked buildings and slab roofs angled downward like wet cardboard. Decades of shoddy and helter-skelter construction visibly marked the social fault lines of the disaster. The building codes for Port-au-Prince were less than two pages long, and it was likely that Léogâne didn’t even have those.31 We’d heard that 90 percent of the town had been damaged or destroyed, but many people were probably living as they had before: in tin-roofed shacks that were almost too small to fail. So in another of Haiti’s ironies, many of the poorer people’s shacks were more or less intact, while concrete Léogâne lay in ruins. Debris clogged the streets, footpaths, and drains; people were pushing wheelbarrows and carrying buckets of water.
As UN officials, aid workers, and locals led President Clinton around, I hung back to get a quieter look at the temporary houses and shelters, called t-shelters. Close to a hundred thousand of them were supposed to be built in Léogâne—that had been the goal—but fewer than thirty had been erected so far. And although the name t-shelter itself suggested impermanence, they were something of a disappointment: solid two-by-fours were used as supports, but the walls were of white plastic; the roofs, cheap tin. Like the spontaneous tent cities, the t-shelters were poised in an uncomfortable space between the temporary and the long term. They were too flimsy to last for long and already threatened by the elements. When I’d worked in Léogâne two decades before, the rainy season invariably resulted in dramatic flooding throughout the city, including the hospital wards, when the local river jumped its banks. It didn’t look like the t-shelters would be high and dry for long.
Soon, private musings about these shelters were echoed by publicly aired complaints from the beneficiaries. The model t-shelter Clinton visited was inhabited by a woman who had nothing good to say about her new home. She launched a stream of invective in Creole even as the disaster-relief folks were describing, in English, the sturdiness of the t-shelters—“these are built to withstand high winds and to serve as transitional shelters that can tide people over until more permanents shelters are built; they’re much safer than tents.” The model inhabitant scowled and complained. “Who would want to live in a house like this? The walls could be split open with a kitchen knife. It’s tiny. I used to live in a three-story building!” The counterpoint was bizarre and discouraging for those who understood both versions of the tale. I was relieved not to be the translator. A Potemkin village this was not.
I was ambivalent about visiting the sugar refinery in Darbonne. Harvesting sugar cane is one of the most brutal forms of labor, and one historically linked to slavery from the sixteenth century on. Anyone who knew Haitian history, remote or contemporary, would be leery about the industry. The harvest was unpleasant in Florida, grueling in the Dominican Republic, and economically unviable in Haiti—again for reasons beyond the control of the cane cutters who were now greeting Clinton. And in all three countries, this harsh work was often done by Haitians.
But as we walked through the mill, my spirits lifted: a thirty-foottall portrait of Jean Dominique greeted us on one of the larger façades. For long years, he had fought the good fight and paid the ultimate price. He would’ve been disappointed by the slow pace of recovery after the quake and sent lots of young journalists out to document the reasons (and excuses) for delays. He also would have deplored contracts without benefits to Haitian firms. So it seemed right to see Jean Dominique smiling over an enterprise that promised to create better prices for the region’s cane growers and cutters.
Haitians weren’t the only workers in this mill, which reared up out of a green sea of cane. The Darbonne refinery had been, since its launch in 1983 on a loan from the World Bank, something of a white elephant. In its best years, it was only marginally profitable because cheap sugar imports—thanks to huge subsidies in the United States, especially—flooded Haitian markets. Another problem was the dwindling harvest: farmers on small plots of land were competing not only with U.S. trade subsidies but also with the technical advantages of agribusiness. Much of the harvest here was still done manually, which meant that cane cutters in Léogâne ended up doing the same sort of work whether in their home country or in any other. They would prefer, surely, to stay home, if they could make a living. After sputtering along for a few years, the Darbonne mill closed, to be re-opened in 2001 when Cuba kicked in $2.5 million in operating capital and a great deal of technical assistance. But the refinery still produced under capacity, providing only 2 percent of the sugar consumed nationally. Haiti, once the largest producer of sugar on the planet, couldn’t compete with Dixie Crystals.
Then along came the call for biofuels, many of them made from sugarcane. Greg Milne, the young lawyer on our team, briefed me on the situation. Three years ago, an energy company invested in the mill to keep it from going under, and it soon generated three megawatts of electricity in addition to scaling up its sugar output (including syrup for alcohol fermentation). Maybe this white elephant would, with Cuban help and some investment, be given a second lease on life. Maybe it would help generate power for a region with little electricity.
At the time of our visit, the plant employed about 250 people. Greg Milne and others estimated that modest investments and upgrades could increase sugar and electricity output tenfold, especially if investments also went to local cane growers to increase their access to tools, credit, and better prices for their produce. Seeing Cuban and Haitian workers on the job, it didn’t seem far-fetched to imagine that initiatives like this one—doing CPR on a moribund refinery—could guide our efforts to resuscitate the foreign aid apparatus. In any case, it seemed like a good use of Cuban expertise, and although the entire biofuels debate seemed impossibly complex, here was an agroindustrial effort that also generated electricity in a rural region that needed it desperately. This combination of potential positive outcomes, and Jean Dominique’s symbolic approbation, made me feel better about visiting this outpost of an industry long associated with cruelty and coerced labor.32
Although my attention was focused on health care
, I was learning a lot on visits like these. As hard as it was to be a cheerleader for sugar production or biofuels, it wasn’t hard to applaud higher incomes for Haitian farmers, more electricity, and more processing capacity. In general, smaller-scale agriculture seemed to strike a better deal for the poor than did industrial and agroindustrial projects. With a fish farm or produce cooperative, farmers, ti machann, and others moving or selling their own produce might in principle enjoy more autonomy and higher incomes than factory workers. But the decline in agricultural production and continued ecological destruction made it hard for anyone tilling the soil or fishing to survive without improved processing capacity and ready access to credit. The microfinance boom had helped some families but had not prevented the rapid rise of food insecurity or the persistence of child servitude.
As noted, Haiti had been buffeted about in the global economy for centuries. Its first transaction, the Columbian exchange, wiped out the indigenous Taino population. (Léogâne, in fact, had been heavily populated by the Taino in 1492, when the global economy was born; its patron saint is the Taino Queen Anacaona.) As noted, the slave labor system put in place by the Spanish and French extracted immense profits from cash crops such as sugar and coffee. Such history tempers any romanticism about sugar refineries, coffee-washing stations, or even mango-processing plants. But on that August day, in the company of a couple of peasant cooperatives, some Haitian investors, a dozen Cuban technicians, and a former U.S. president, it felt good to leaven a visit to troubling temporary shelters with an effort to create jobs and electricity and processing capacity. Although anxious to return to medical tasks, I knew that poverty-reduction efforts, better wages, and improved access to the fruits of modernity would make our medical work easier and more effective.
Such were the insights of social medicine, a discipline I learned from Haitians and from mentors at Harvard. It was social medicine we tried to practice in Haiti and elsewhere in the world, from the poorer parts of Boston to the rural reaches of Rwanda, Malawi, and Lesotho. But the masters of this field were surely the Cubans, who, along with Aristide, had founded a new medical school in Haiti. The school was one among many worthy efforts shuttered by the 2004 coup. Most of the students had been able to continue their studies in Santiago, Cuba, however. At the close of a summer in which no students would graduate from Haiti’s state medical school, sixty-seven newly minted doctors were due to receive their diplomas. One had been born and raised in Cange, and most others were from similarly humble backgrounds. I’d been one of the only American doctors involved in their first year of training and was honored to be asked to be the parrain—literally, the “godfather”—of their class. (The godmother chosen was Marie-Laurence Lassègue, to whom I’d handed my satellite phone amidst the din of Toussaint Louverture Airport not long after the quake.)