Haiti After the Earthquake

by Paul Farmer

  By 2010, the country would have been almost unrecognizable to the pessimists. Kigali, the capital city, was bustling and clean; new buildings were going up in droves. The country’s GDP had more than trebled in the preceding decade. Education and health care had become, over those years, far more available to the average citizen, and an anticorruption campaign had yielded fruit: a good deal of investment poured in from abroad, from the large diaspora, and from within Rwanda itself. In 2010, hundreds of NGOs were still in the country, but coordination with local and national authorities was the rule in every sense of the word. The country’s national development plan predicted that, by 2020, Rwanda would no longer require foreign assistance.

  After working in Haiti and Rwanda for several years, I’d become accustomed to tracing a triangle between Haiti, Harvard, and Rwanda. In September, for long hours en route to Africa and back to Haiti, stuck in planes, I thought mostly about reconstruction. One vision of reconstruction that I’ve repeated passim at the risk of sounding like a broken record was rebuilding public infrastructure to strengthen sovereignty and basic social and economic rights. Although building back better seemed already a tired cliché, Rwanda had built sounder structures, reshaped its engagement with foreign aid, and expanded human capacity by investing in health, education, and gender equity. Could those billions pledged for Haiti’s reconstruction be translated into a plan like this one? Could some of the larger projects generate jobs that would transfer skills and draw some of the diaspora back to Haiti?

  Questions like these led us back to our plans for the Mirebalais teaching hospital, our most ambitious effort to date. We sought commission approval not for funding—we had raised most of the money—but for legitimacy and coordination with other reconstruction efforts that fit into a national plan. The last stop on the triangle was thus central Haiti, where we were about to lay the hospital’s cornerstone.

  Mirebalais was, in a way, the birthplace of Partners In Health. Many of the founders (Ophelia, Father Fritz, and Mamito) and other supporters (including Didi and her family) had first met there in 1983. That year, almost three decades ago, we began to understand the poor quality of medical care available in rural Haiti. Although I hadn’t yet started medical school, it didn’t require an M.D. to understand that a five-minute exchange with a harried Haitian doctor with no lab or other diagnostics was not the recipe for delivering care. And it didn’t require a degree in pharmacology to imagine that the various potions poured into corncob-stoppered bottles were not likely to have more than a placebo effect—or worse.

  My experiences in Mirebalais that first brutal and instructive year inspired a life-long desire to see, in Haiti, a hospital worthy of its people. The devastating storms of 2008, and President Clinton’s inclusion of Haiti at the 2008 Clinton Global Initiative, were links in a chain of events that led to an ambitious vision for the hospital. A young philanthropist, who was committed to the struggle against human trafficking, met with me and a coworker from Partners In Health and pledged, right then and there, a lead gift to rebuild the Mirebalais hospital. We suggested that some of her anonymous pledge supplement salaries for beleaguered health providers, train community health workers, and improve the existing facility (along with Cuban help). It would take at least a year to design the hospital and raise the rest of the necessary capital. “I trust you,” she said, promising to visit in 2009. That visit was delayed until January 2010. She sent an advance team down to Haiti in preparation for her visit, and the team had the ill fortune to be in the Hotel Montana on the day of the earthquake. Both were injured badly but survived.

  The quake made us rethink the project completely. With the nursing school destroyed and the medical school damaged and closed, with most of Port-au-Prince’s hospitals down or in disrepair, where would the next generation of Haitian health professionals train? As noted, Alex Larsen, the Health Minister, asked us to make it a major teaching hospital. Partners In Health supporters, including new corporate donors, had sent thousands of donations for rebuilding. Why not try something really bold and beautiful?

  The stars seemed aligned in other ways, too. Ann Clark, a classmate of mine from college, was now an architect and married to another architect; she had dragooned her small firm and family into redesigning the hospital plans.41 One of my former students, David Walton, was committed to a thorough overhaul and expansion of the project. Both he and the architects hailed from Chicago and had rallied donors and companies there to the cause. Even more remarkable, a former construction company owner from Boston, Jim Ansara, had been practically living in Haiti since the quake, helping to assess the structural integrity of buildings and running from hospital to hospital. He was ready to pour time and resources and connections—his own and his company’s—to make this one bigger and better. Together, this crew revised the plans more than a dozen times, ever growing their scope and making it, in the end, a 160,000-square-foot medical center. This was three times the size of anything we’d ever attempted to build before.

  Mirebalais is the largest town in Haiti’s lower Central Plateau. Even while shaking off jetlag, it was easy to sense the optimism of our Haitian coworkers and others who’d gathered there to lay the cornerstone. Heavy rains had fallen the previous night, and some of our coworkers (including David and Jim) had been temporarily stranded on the far side of the river that runs through the city. (The same bridge that had been destroyed by the 2008 hurricanes, now traversed by a simple concrete ford, often underwater.) But the waters receded and the morning of September 10 dawned hot and sunny; it was sweltering under the tent in which we gathered to launch the hospital. Part of the construction site had already been leveled, and more site preparation (moving more than an Empire State Building’s worth of dirt) was needed before the foundations could be laid. Although this sounded dauntingly large, those gathered brought experience and a shared commitment to bear on a project that could help Haiti recover and maybe even flourish.

  The Minister of Health was there, as were his senior leadership team, in part because the long-awaited hospital was also the first major health project approved by the Interim Haiti Recovery Commission. (Its logo showed up, among others, in the slideshow playing in the background.) Father Fritz gave the benediction. This was one of the first times he’d left Cange since the funeral mass for Mamito. The lead architect, my college friend from Chicago, presented the plans to an audience that included local officials, UN workers, the Cuban Vice-Minister of Health (accompanied by a handful of the thousand Cuban health professionals volunteering in Haiti), supporters of Partners In Health, and the Haitian medical staff. Construction teams from Haiti, the Dominican Republic, and Boston, including those stranded at the site the previous evening, were in attendance, as was Shelove, the proud physical therapist. Her limp was not perceptible; nor was my brother-in-law’s. He had recovered quickly from his fractured ankle and had, since the quake, joined Zanmi Lasante’s women’s health team.

  In spite of the heat, no one seemed to mind a long morning of pronouncements. After the opening invocation, the Mayor spoke, followed by Haiti’s leading health officials. I had a chance to say my bit, too. For weeks after the quake, the best hospital in Haiti was floating in the Bay of Port-au-Prince. It was our hope that one day the best hospital in Haiti would be anchored on terra firma and followed by others in Port-au-Prince and elsewhere in the quake zone.42

  But as ever in Haiti, feelings of pleasure and satisfaction were soon crowded out by anxiety and even dread: anxiety, for many of us, about how we were going to run such a hospital once it was built; and dread because a new epidemic, long feared, was about to hit Haiti. And it would first appear, in all places, in the city of Mirebalais.

  7.

  RECONSTRUCTION IN THE TIME OF CHOLERA

  The third week in October found me back in Kigali, where I received a message from Louise Ivers about a new problem emerging in Mirebalais and Saint-Marc. On the afternoon of October 19, our colleagues in Saint-Marc, a large coastal town where
we’ve worked for only a few years, alerted us to the sudden arrival of scores of people suffering from acute watery diarrhea. Some patients were carried to the hospital on makeshift stretchers; others walked in unassisted but collapsed while waiting to be seen. After seeing similarly afflicted patients, a hospital further inland (the one where Shelove had been fitted for her prosthesis) issued a brief report predicting an outbreak of typhoid—a longstanding curse in Haiti, which just a few years ago was named the most water-insecure country in the world.1 Upon hearing the details from Saint-Marc, I remember thinking, let’s hope it’s typhoid.

  But this diagnosis seemed unlikely to me and to Louise, also an infectious disease doctor. Very few pathogens provoke the secretory diarrhea that was felling these patients in Saint-Marc and Mirebalais, and typhoid is not among them. For months we had been dreading the outbreak of a disease far more virulent than typhoid and known to mow through refugee camps and slums lacking clean water and sanitation—especially after wars and disasters natural and unnatural.2

  After the U.S. Centers for Disease Control and Prevention had in March deemed cholera “very unlikely to occur” in Haiti,3 why did we suspect that it was the cause of the influx of patients with acute diarrhea? First, cholera has an unmistakable clinical presentation. Infectious disease doctors would be hard-pressed to describe another diarrheal disease that can shrivel a hale adult in a matter of hours. (It makes even shorter work of children, the elderly, and the malnourished.) The last major epidemic in the Americas lingered in post-conflict Peru for three years, killing an estimated ten thousand before being brought to heel in 1994. (I’d seen the tail end of this epidemic during my first visit there.) Second, Haiti was an ideal host for cholera: even before the quake, it had little in the way of municipal water and sanitation systems, and had long been a mineshaft canary for epidemic disease. It was something of a miracle that Haiti had been spared cholera for so long.

  Some had foretold the spread of such waterborne diseases years earlier. I’d issued this warning to the Senate Foreign Relations Committee in 2003, and again after the quake. When a series of Inter-American Development Bank loans to Haiti were blocked for political reasons in 2001, the projects they were intended to support—including one for water infrastructure improvements in Saint-Marc—lay fallow.4 In 2008, we were still waiting. At the site of another delayed municipal water project in the north, the drinking water samples were polluted with human waste. (One of our young researchers there promptly fell ill with typhoid.) All this was years before the earthquake would render Haiti even more vulnerable to waterborne disease.5

  In a sense, cholera had been waiting for us. We ought to have been more prepared. Once dreaded in cities throughout the world, including those in Europe and North America, cholera has become, with the advent of modern sanitation, a disease limited to developing countries—especially those riven by conflict. Today, it is the worst nightmare of doctors working in shantytowns and refugee camps. The key to treatment is rehydration: replacing the fluids and electrolytes lost through explosive, watery diarrhea. Because cholera is caused by a bacterium, antibiotics have a role to play, too. Sitting in Rwanda, which has had its share of cholera, and thinking about the outbreak in Peru, I hoped we could avert many deaths even if we could not avert an epidemic.

  Or perhaps this diagnosis was wrong, and the outbreak was not caused by cholera. Perhaps we’d have a chance to pursue water and sanitation projects more effectively. But late that October night, Louise called me to say that, although the laboratory work had not been completed, the news would be bad. After a century of reprieve, cholera had returned to Haiti.

  If the first nine months of the year were dominated by the earthquake, the last two seemed to consist of nonstop cholera. The earthquake laid down the conditions for an epidemic of waterborne disease but by no means made it inevitable. Some conditions predated the quake; some became recognizable only in retrospect. Cholera was the latest acute reminder of Haiti’s integration into the global economy and its paradoxical privation—of its place in a vast transnational web and of its exceptional dearth of public services. In the Republic of NGOs, private initiative could not conjure functioning municipal water systems and decent sanitation infrastructure out of thin air. Without all the medical equipment, facilities, or medication we needed, without rapid integration of all necessary preventive measures and treatment, we would be in trouble.

  By the last week of October we knew that four things were likely to happen in short order. First, the epidemic would spread rapidly across the country, since Haiti was fertile ground for any waterborne disease caused by a bacterium that could survive, even briefly, outside a human host.

  Second, effective means of treatment and prevention would be quite limited in many areas and almost nil in others: those with ready access to clean water would be spared, and those without would not. Those with access to prompt diagnosis and proper care would survive, but many thousands without access to care would die. There was every reason to believe, from the first cases documented, that this would be a devastating epidemic that could not be limited to central Haiti, or limited to Haiti at all.

  Third, we knew from previous epidemics that loss of life, especially among the young and previously healthy, would trigger cycles of accusation and counteraccusation. Blame was, after all, a calling card of all transnational epidemics, including the AIDS epidemic.6 As with AIDS, the introduction to an island of a previously unknown infectious pathogen would implicate transnational spread. Cholera had to have come from somewhere.

  The press to discover whence this new malady hailed would reflect the desire to know whose fault it was. Anthropologists often trace modern Haitian ways of explaining misfortune to the slave plantations from which Haiti was born. A wonderful essay about folk healing by Karen McCarthy Brown puts it this way: for the early Haitians, “natural powers such as those of storm, drought, and disease paled before social powers such as those of the slave holder.”7 Although explanations for the earthquake were natural (except among well-nourished American TV pastors), social responses would include local cycles of accusation, drawing on village-level feuds. Other accusations would be vaguely nationalist: Social turbulence around these themes would, predictably, complicate responses to the epidemic. Instead of “What brought this latest misfortune down upon us?” I expected to hear, “Which foreigners brought this latest misfortune down upon us?”

  Fourth, expert opinion on cholera would be divided. Prevention experts would focus on their methods of protection (from water filtration to chlorination to vaccination) and treatment experts on their means of treatment (from oral rehydration to antibiotic therapy). There would be disagreements about priorities and investments. I’d seen these arguments during the Peruvian epidemic and read about them during the Zimbabwean one.8 Conflicts of this kind seemed less to do with cholera than with long-standing divisions between medicine and public health. We’d encountered these same divisions when responding to AIDS and tuberculosis and malaria and cancer: instead of efforts to integrate prevention and care, there was brisk competition between those working in prevention and those seeking to provide care.

  Some—like the Cuban brigade, GHESKIO, and, I think it’s fair to say, Partners In Health—have long advocated the integration of prevention and care as leading to better prevention and more comprehensive care. But others pushed for their own areas of expertise and favorite solutions, leading to competition rather than cooperation; prevention versus care; water protection versus vaccination (or even chlorination versus filtration); regional versus national plans; oral rehydration versus antibiotic therapy; hand washing and small waterprotection projects versus municipal water projects. This, in any case, is what we feared.

  All four of these predictions came to pass. The cholera epidemic hit central Haiti—even more water insecure than the internally displaced persons camps—like a bomb, spreading from town to town and then into villages far from any clean or filtered water source. As for the rapid
ity of spread, the numbers spoke for themselves. No cholera epidemic stays local for long, and the Haitian one moved fast. I had heard of the outbreak in the third week of October from colleagues in Mirebalais and Saint-Marc, two cities connected by a river. It reached Port-au-Prince by November 9 at the latest, when cholera was diagnosed in a child who had not traveled outside the city.9 Soon cases were reported across the nation. By the close of the year, almost two hundred thousand cases were registered in Haiti’s ten departments, and nearly four thousand of those afflicted had died.10 Given weak reporting capacity, these estimates were probably low. The Haitian epidemic is the most devastating the hemisphere has seen in decades.

  The cycles of accusation and counteraccusation started, as predicted, on day one. Louise Ivers and David Walton had given me a heads-up, as I paced about in Rwanda. Although the world became aware of the epidemic when it reached Saint-Marc, there had almost surely been cases several days earlier far from the coast, in the region closest to the Nepalese peacekeepers whose base sits on the banks of the Meille River. Because that river flowed by the Nepalese encampment into the city of Mirebalais, a causal link was quickly posited, and not just by epidemiologists: much of the local citizenry believed that a new pathogen had been introduced by the foreigners in their region. Most of the foreigners in Mirebalais were UN peacekeepers, the great majority, in fact, from cholera-endemic countries.