by Paul Farmer
I didn’t know what to do for these young men and women other than to welcome some of them to our hospitals as interns. Claire and Loune suggested I give them each a stethoscope and one of my books. The ceremony took place at the Karibe Hotel, which, though damaged in the quake, was open for business. I didn’t have to speak, and just sat there with Minister Lassègue and other dignitaries (the Cuban and Venezuelan ambassadors, and the leaders of Haiti’s Ministry of Health), to celebrate the return to Haiti of this bumper crop of Cuban-trained doctors. Thirty of them approached me after the ceremony about forming a study group to stay in touch and keep learning. (They would be scattered across Haiti after years of study together in Cuba.) Most would have too little support—in the way of clinical supervision or didactic sessions—so some younger U.S.trained doctors, including Natasha Archer and Michelle Morse, promised to help mentor them and connect them to a web-based platform we’d developed at Harvard. The students were full of trepidation and enthusiasm.
The graduation ceremony was one of the happier moments of the summer of discontent, and it made me all the more anxious to see the Mirebalais hospital up and running. It was possible, just then, to imagine a time when these young physicians could work in a hospital worthy of their talent and training.
The ceremony was also a reminder of my own students and the Department of Global Health and Social Medicine at Harvard, which I chaired. The work in Haiti was central to its mission, but the new academic year was about to begin. Classes would start soon, and I was unprepared. For the previous eight months, it had been all earthquake, all the time. It was daunting and emotionally difficult to think about teaching anything unrelated to the health challenges after the quake. What lessons could be drawn from the previous eight months? What links existed between short-term relief and the long slog of reconstruction? Observers and participants alike were struggling to make sense of what had transpired since the quake. There were plenty of stories and reports noting how little had been achieved. But most of the conclusions seemed premature: it was early to say much about the pace of reconstruction, other than that it was slow. And the pace would have been slow in less devastating circumstances, as we’d learned after the storms of 2008.
There were also other projects to keep going (and growing) in a dozen other countries. We were behind schedule to open the flagship public hospital in Rwanda’s Burera district.33 It would be smaller than the one we were starting in Mirebalais but was nonetheless the largest we’d built to date, and we’d poured blood, sweat, and tears into it. In fact, the hospital was a poster child for swords-to-plowshares projects because it lay on the site of a former military base near the Ugandan border. We launched the project with the Rwandan government and broke ground in the summer of 2008. We’d promised a glorious product by the close of 2010, and were a month or two behind. These promises, and others made outside Haiti, found their way back into my thoughts as August drew to a close.
I gave my first class of the year at Harvard College rather than the medical school (where I usually teach). The course was called “Case studies in global health” and, on September 2, I began with a presentation about the earthquake, the social roots of the disaster and the challenges to delivering care in its aftermath. To end on an authentic but optimistic note, I showed a brief video about Shelove and Carmen, both of whom stayed on in Cange and had been trained as physical therapy aides. At the time of writing, both had emerged as excellent accompagnateurs for other amputees—accompanying them on the long and painful road of recovery.
At my request, Shelove began looking after one patient: a young man named (believe it or not) Victory, who was suffering from tuberculosis and Hodgkin’s lymphoma. When he arrived at the hospital, Victory weighed less than seventy pounds and was too weak to stand. After receiving treatment for both his afflictions, he was soon walking again. His progress was thanks mostly to his treatment but also to Shelove, who helped him get up on his feet again. Many in his shoes would be tempted to give up. But Victory received more or less the same medications he’d have received in Boston, plus something else: accompaniment by a survivor.
The video showed the women talking about the experience of losing limbs in the quake and of their new lives, making rounds with patients of their own just a few months after their amputations and rehab. Seeing Carmen trudge uncomplainingly to visit the homes of people disabled by all manner of ailments made me hope that the quake might have triggered a genuine disability-rights movement, long overdue in Haiti. I wanted to share with our students that there had been inspiring stories in post-quake Haiti—although they were rarely mentioned in the mainstream press, Haitian or American. The failures were always more noteworthy. “When I go to see patients, I show them how to walk,” said Carmen. “I accompany them as they learn to use their wheelchairs. I talk to them. They ask me how I’m able to walk, if my prostheses hurt, if I’m able to run, if I can do whatever I want with them, and I say yes. I had thought I would never walk again, but now I can do whatever I want. My life has been changed.”
Sanley, whose amputation had been delayed for weeks in vain hope of a limb-sparing procedure, was not featured in the video, but she has also done well. She remained in Boston with her mother; both were studying English. Sanley seemed like her teenage self again. When I’d last seen her in a cafeteria at Harvard Medical School, she was busy on a new computer using Facebook to find friends in Haiti. In the months after her rehabilitation, Sanley appeared on television with one of Boston’s best-known chefs, a Partners In Health supporter named Jody Adams who’d participated in “America’s Top Chef” to raise money for our work. In the cook-off, in which the chefs had been presented with a culinary challenge, Jody’s included goat. She didn’t win. A few months later, Sanley and her mother and Jody made a guest appearance on another show, seeking to improve Jody’s goat-cooking skills. I didn’t share Sanley’s story with my students, but she was on my mind as I struggled through the lecture.
In keeping with the course’s structure, the other faculty present responded to my remarks. The first respondent was Anne Becker, a psychiatrist with whom I’d trained in medicine and anthropology. After her first year of medical school, Anne had worked in the Port-au-Prince slum called Cité Soleil. She ultimately decided to do her doctoral research in Fiji, which turned out to have equally troubling, if less apparent, social pathologies as Cité Soleil. We’d been friends for more than twenty-five years. The second was Anne’s and my mentor, Arthur Kleinman, also a psychiatrist-anthropologist, who had defined the field of medical anthropology through his long-term work in China. It was the third year we’d taught the course together, but the first time we’d shared a classroom since January. I regarded both of them as giants in the field of social medicine, and wondered what they’d say about the earthquake.
Anne Becker’s comments were more informed by knowledge of Haiti. After the quake, she had returned to Haiti to visit one of the country’s only psychiatric hospitals (her first trip back since the summer she spent in Cité Soleil). She expected, correctly, a near-total lack of medications in the damaged hospital, but this was not the problem the few caregivers there emphasized. “We need food and water,” they said. “And mattresses and sheets and clothes for the patients.” They also needed medications, of course, but were forceful in their ranking of needs.
Arthur Kleinman responded to my lecture by drawing on his prodigious knowledge of China. He told the class about the varied responses to two major quakes there. One, centered in Tangshan, may have killed as many as 750,000 people. But this staggering loss occurred in 1976, and the Maoist ideology then regnant led the state to bury many of the facts along with the victims. Its sorry history, Kleinman said, is only now being written. The Sichuan quake in 2008 claimed 68,000 lives and destroyed as many as fifteen million buildings.34 It attracted significant media attention because, this time, the Chinese government allowed greater access to local and international press. The government also permitted volunteers independent
of the party-state to participate in the relief effort. The response was massive: in addition to 130,000 soldiers and several thousand dispatched construction workers, some 150,000 volunteers from local and international aid organizations traveled to the quake zone to help.35 “Never since 1949,” noted Kleinman, ″had the Chinese authorities allowed civilian volunteers to offer their services in a social space in which the state claimed capacity and authority.”
Much had been made (in this book and in the meetings I’d attended) from comparisons to the Asian tsunami, but Kleinman’s contrast of the two quakes in the same vast and changing nation was telling. The challenge was the same: which lessons were specific in their implications and which were generalizable? Since January 12, countries as different as Japan, Cuba, Mexico, and Brazil offered pragmatic assistance to Haiti by drawing on their own experiences with natural disasters. Some of this assistance had already proved helpful. But the circumstances in Japan and China and Brazil—and even neighboring Cuba—seemed so different from those in Haiti. Even when the acute insult—an earthquake or a hurricane—was the same, the chronic malady was very different. Haiti’s problems seemed greater though this was not an easy point to make. I again found myself thinking of Rwanda, which seemed more like Haiti than did the other countries mentioned that day.
I was thinking of Rwanda for other reasons, too. En route to Kigali that evening, I had grabbed the previous day’s New York Times in the flight lounge. Its lead editorial was titled “Katrina, Five Years Later.” Positive notes were sounded, but with a warning: “The region faces huge challenges. The dearth of affordable housing casts a long shadow on the city’s future. At the moment, nearly 60 percent of city renters spend more than 35 percent of their incomes on housing—normally about 40 percent of renters spend that much. These people skimp on nutrition and medical care, undermining the wellbeing of children, and are chronically at risk of homelessness.” The editorial noted that, “with 55,000 abandoned addresses, New Orleans is probably the most blighted city in the country.”36
I immediately thought of the students I’d taught that morning, wishing I’d shared this piece, because it said a lot (if indirectly) about the burdens of chronic weaknesses when dealing with acute problems. Anyone reading this article in Haiti would have thought of the camps. What might they look like in five years? What was the long-term prognosis for Haiti?
Certainly, there are platitudes and long-existing frameworks of interpretation regarding all that happens in Haiti and about the failure of the development enterprise there. Even over the past few years, several books have been written on these topics, and some tried to do the same decades ago.37 One common platitude concerned the resilience of the Haitian people. The problem in dismissing the resilient-Haitian angle is that sometimes, as the stories of Shelove and Carmen and Sanley suggest, it was true. But then again, they had access to three things that many Haitians lacked: health care, training, and jobs. Those affected by the quake also needed these services, just as they needed water, food, and shelter.
As President Clinton predicted on the day of the quake, the shelter dilemma remained the ranking problem in Haiti. The number of people in camps—as many as 1.5 million—had not budged much over the summer. The reasons for the slow rate of resettlement were varied and complex, but chief among them were three. First, the majority of those in the camps did not own the houses that collapsed around them on January 12. They were renters, and in some cases squatters, who put huge fractions of their scarce resources—larger even than that invested by the people of New Orleans post-Katrina—into housing and food and education. Second, these services, as well as medical care, were difficult to access before the quake and at times were more readily available within the tent and tarpaulin settlements. Third, rubble removal had been slow. Omnipresent debris—“a cancer in the city,” said Clinton during one August meeting—made it difficult for people to return even to intact houses. Thus did the camps stay full during the summer, even though the rains left them fetid and unsafe.
Tempers were increasingly short inside the camps. But what could be done to speed up reconstruction? The Haitian government wasn’t idle on this front. By the March 31 New York donors’ conference, an action plan (one cobbled out of several) for reconstruction was ready. In April, the Interim Haiti Recovery Commission created by presidential decree was passed by the fractious parliament. (Such work was conducted in makeshift buildings and shelters because both palace and parliament had been destroyed.) It took another month to stand up the beginnings of the commission within a tent (air-conditioned, but a tent nonetheless) and a month or so to organize the first meeting. Although it’s unclear by what standards the speed of this response was being judged, an August 29 editorial in the New York Times sounded a rare optimistic note:The Interim Haiti Recovery Commission was set up after the Jan. 12 earthquake as a joint Haitian-international effort to effectively channel billions of dollars of donated reconstruction aid. Like everything else about the recovery effort, the commission, led by Prime Minister Jean-Max Bellerive and former President Bill Clinton, has been too slow off the mark. But we were encouraged by its second meeting in Port-au-Prince this month, where it announced dozens of new projects with clear benchmarks and the commitment of more than $1 billion to complete them.38
At the top of the list of projects was the removal of an additional one million cubic meters of rubble (as noted, only 2 percent had been cleared by mid-September39) and the construction of temporary hurricane shelters able to protect five hundred thousand people—both by November. These and other projects would require a smooth and rapid flow of capital and human resources, if they were to be completed on a tight schedule. On one point it’s important to quibble with the Times: billions of dollars had been pledged to reconstruction rather than disbursed. No small amount of that capital was tied up by politics and by a concern with process that led to such caution and to a certain divorce from the sense of urgency appropriate to the raw need on the ground. Reconstruction funds were not, in fact, readily available in Haiti. This obsession with process, and the strictures of what the great sociologist Max Weber called “the iron cage” of bureaucracy, led to the rather underwhelming temporary shelters we’d visited a month earlier in Léogâne.
In the long term, meeting cherished social goals—from reconstruction to universal access to primary schools and health care—would require not just aid but also economic growth. In the short term, however, enough had been pledged so that many basic needs could be met if funds were disbursed and projects implemented. In health and education, implementation must be done through the public sector: how can there be public health or public education without a public sector?
How to break the vicious cycle of a functionally incompetent public sector leading to further inefficiencies and incapacity in providing public goods? This question is the subject of great and often ideological debates throughout the world, and we should mistrust those who profess overly confident answers. The answer surely is not to further starve the wounded public sector—however badly wounded it might be. Yet that’s what was happening. By September, approximately 15 percent of the March reconstruction pledges had been met, and only 0.3 percent of the $1.8 billion in relief assistance went the public sector. (The Times editorial mentioned that, in testimony before the U.S. Congress, I had complained that only 3 percent of this aid went through the public sector; I had overestimated by a factor of ten.) What was clear even before the quake was that this approach might sustain the NGOs and the multilateral aid machinery in Haiti but wouldn’t suffice to build adequate capacity in the Haitian public sector itself. Nor would the established system of awarding contracts to beltway bandits (or even high-performing aid contractors) engage Haitian companies small or large.40 If business continued as usual, neither the public nor private sector in Haiti was poised to accomplish much in the way of reconstruction, in spite of the best intentions of many of those caught up in Weber’s iron cage of bureaucracy.
Fi
nally, the Times editors also mentioned the Mirebalais teaching hospital, which had been one of the five health programs approved by the commission in its first meeting to consider such projects. Because we’d been involved in this city in central Haiti for almost three decades, and had for almost two years been pushing for a proper hospital there, I’d like to proceed by describing in more detail how this goal—to have a great hospital in central Haiti—was changed, indeed upgraded, by the quake. Some of the lessons we’d learned had been in Haiti, of course. But we’d also learned a great deal from Rwanda.
In 1995, Rwanda, still reeling from the genocide, was by many measures the poorest country on the face of the earth. It would be hard to imagine a tougher situation—even comparing it to Haiti after the quake. Although Rwanda lost neither a third of its housing stock nor all its federal buildings, it had surely lost more than a quarter of its civil service. Many of the other surviving civil servants were themselves deeply involved in or tarnished by the genocide. After the cessation of hostilities in Rwanda, scores of humanitarian groups and NGOs (small and large) jockeyed for position; most did not care to coordinate their efforts with other NGOs, much less with the interim government trying to restore order and basic services. To the west, in refugee camps in Zaïre, hidden among the real refugees, were many of the architects of the genocide. International arms dealers were still shipping them weapons, and cross-border raids and clashes were continuing apace. Rwanda’s rich farmlands lay fallow and hunger was rampant. Many international observers were willing, in 1995, to write off Rwanda as a lost cause.