Haiti After the Earthquake

by Paul Farmer

  Although many NGOs still preferred to work on their own or in collaboration with other members of “civil society,” some of the big players were beginning to rethink the merits of public sector engagement. Try as they might, the dozen or so NGOs working at the General Hospital could not keep the place afloat. The hospital, months after the quake, still faced the double burden of the biggest caseload in the country and perhaps the biggest facility funding shortage. But international NGOs had raised millions of dollars for earthquake relief. Trying to connect the dots, we went to the American Red Cross and asked them to invest money in salaries for nurses, janitors, surgeons, and others at the General Hospital. It took convincing by a number of people (including President Clinton), but they said yes. The Red Cross provided—through what was for them a modest grant—invaluable medical equipment and staff salary support.

  NGOs had many other opportunities to accompany the public sector as it struggled to rebuild the shattered health system. The story was the same in public education and, as cholera reminded us, public water and sanitation. But beyond the cluster system, how could the machinery of foreign assistance better coordinate funding flows and the division of labor to strengthen public institutions and generate long-term reconstruction?

  The Interim Haiti Recovery Commission sought not to be yet another cog in the vast machinery of foreign aid, but rather to introduce some transparency and coordination to the process. It leant a seal of approval to projects—whether from NGOs, contractors, or line ministries—that fit within the national plan, and then tried to patch together funding for approved initiatives. The commission would also track pledges and disbursements to prevent donors from defaulting on their promises and grantees from failing to make efficient use of funds.

  These failings of mainstream aid in Haiti were, of course, well-known. 48 The rebuilding efforts (or lack thereof) in Gonaïves after it was ravaged in 2004 by Tropical Storm Jeanne were a case in point. As bad as parts of New Orleans looked four years after Katrina, the city of Gonaïves was, on the eve of the 2008 storms, almost completely unrestored by the money pledged after Jeanne. It was never clear how much of it ever reached Gonaïves, or Haiti for that matter, because there was little in the way of tracking mechanisms at that time.

  The end of 2010 was too early to tell whether the new Recovery Commission would work. If it fails, it would probably be because the body lacked teeth and had to rely on the goodwill of all parties. In its first three months of existence, the commission approved reconstruction projects worth $3 billion, but unmet pledges meant that most of these projects remained incompletely funded or not funded at all. It wasn’t clear why, other than the usual bureaucratic siloing, major funders had not put more resources into the commission. Some argued that the commission existed only to green-light projects lacking sufficient resources. But this was circular reasoning, especially when made by those who themselves control many of the resources: what good was a stamp of approval if projects lacked funding for implementation?

  Case-by-case investigations of where the money was stuck revealed, as noted, foreign-grown political obstructions and bookkeeping tricks but also the very real lack of what aid specialists call “absorptive capacity.” Haitian institutions, public and private, have been long starved of resources; a massive influx of funds, unless carefully distributed and monitored, could have overwhelmed them. But some of the build-up was merely the wait-and-see approach characteristic of the foreign aid enterprise. If the commission were able to shepherd some large-scale projects forward in the early days of reconstruction, it could grease the skids for future projects and begin to serve its purpose—improving aid efficiency and effectiveness and transparency and speed.

  If the commission fails, and if development assistance in Haiti remains mediocre, it’s easy to guess who will be blamed: those who stuck their necks out for more a nimble and transparent process. But the default mode is to blame the Haitians: their culture, institutions, and lack of ownership over reconstruction and development schemes. And as of late October, the way aid was flowing—or rather, the way obstacles were appearing to curtail its flow—seemed to augur a future in which Haitians not only lack sufficient resources for a massive, New Deal-style job-creation campaign, but also are themselves held accountable for any failure. (Such accountability becomes a further reason to deny them support.) That was what happened after the four storms of 2008, after the flooding of Gonaïves in 2004, and after so many disasters natural and unnatural over the course of Haitian history. At the close of the year, the Haitian government was receiving few foreign assistance dollars and collecting little in the way of taxes.

  Knowing that billions of dollars have been spent in Haiti over recent years can lead to cynicism about aid effectiveness. Tim Schwartz and several others have offered scathing assessments of the failure of development assistance in Haiti. The challenge before such critics—and I’m one of them—is not just to diagnose the problem but to fix it. Some aid agencies and foundations, paralyzed by failure, have been, at times, reluctant to work in Haiti. But they returned soon enough after the many crises of the past years—storm, flood, famine, quake, displacement, epidemic disease. The trouble was that no famine or refugee crisis or cholera epidemic was solely a natural disaster. They were always social disasters, and almost never local in their etiologies.

  This insight is not new: Mike Davis made this point about what he called the “late Victorian holocausts”—a series of famines that occurred not in isolated backwaters but rather in settings firmly integrated into the British Empire.49 These famines were the result of policy decisions made far from the famine-affected areas, just as the late-twentieth-century collapse of Haiti’s rice production was triggered by biased trade rules set in North America and Europe. Small-scale Haitian farmers could not compete with huge First World agricultural subsidies after Haitian import tariffs were removed as part of strangely labeled free-trade agreements. 50 These policies were of course designed without the agreement of Haitian farmers, who then watched their livelihoods slip away within the space of a few years.

  Unfair trade policies were nothing new, as any Haitian historian could tell you. What was new, or newly significant, was the rise of a massive machinery of humanitarian assistance, much of it rooted in the private sector. In the last few decades, the number of NGOs exploded, in large part because of the great and unattended needs of the increasingly unequal world. In a damning new book, The Crisis Caravan: What’s Wrong with Humanitarian Aid?, Linda Polman dates this explosion not to the nineteenth century, when the Red Cross was founded, but to the Biafran War of 1967–1970, which led to the first televised famine and as stirring an international response as had been seen since protests over Belgian rule in the Congo a century ago.

  Polman offers an unsparing ethnography of humanitarian assistance: “Wars and disasters generally attract a garish array of individual organizations, each with its own agenda, its own business imperatives, and its own institutional survival tactics.”51 The Haitian earthquake certainly attracted an array, garish enough, of organizations, each with its own imperatives and plans. By the fall, some of these organizations had already moved on to the next disaster. But plenty more were in Haiti to stay, joining an already dizzyingly complex mix of international NGOs, local NGOs, church groups, and mainstream purveyors of development assistance. Writing just after the quake, Mark Danner called Haiti “the great petri dish of foreign aid.”52 Few would agree that it has been a successful experiment.

  The pitfalls of humanitarian aid are becoming better known. Indeed, careful consideration of more recent humanitarian disasters, especially those linked directly to strife, offers scant hope for the business-as-usual approach to disasters natural and unnatural. Philip Gourevitch reviews Polman’s grim book and several others in a recent New Yorker essay, “Alms Dealers.” He summarizes the arguments of the now “groaning bookshelf” of aid critiques by echoing Polman’s argument: “Sowing horror to reap aid, and reaping aid to so
w horror, [Polman] argues, is ‘the logic of the humanitarian era.’”53 The logic of assistance that focuses on funneling resources to the NGOs large and small, and its unintended consequences, were played out in dramatic terms in Africa (Nigeria in the late sixties and the Great Lakes region and Horn of Africa from the eighties until today) and in Southeast Asia (Cambodia).54

  Those first weeks after the quake, when rescue and relief workers poured in, seemed animated by a different spirit than that evoked by Polman and other aid critics. There was much goodwill and generosity; and there still was almost a year later. But we ignore these critiques at our peril. It’s useful to consider each of Gourevitch’s examples and reflect on the current Haitian dilemma. Doing good is never simple. He invites us to “consider how Christian aid groups that set up ‘redemption’ programs to buy the freedom of slaves in Sudan drove up the market incentives for slavers to take more captives.” This dramatic example has echoes in modern Haiti: the political economy of servitude underpins not only the Haitian restavèk tragedy, linked as it is to both poverty and the lack of public education for all, but also the hardship of the braceros who cross the Dominican border to harvest sugar cane under conditions denounced as slavery as recently as 2003 .55 Growing inequality, both within countries and between them, is the linchpin of modern servitude and weakens the ability of those with the best of intentions to avoid perverse consequences. Efforts to prosecute those who rely on children for domestic labor are less likely than structural interventions—making sure that children go to a school where they might receive sound instruction and at least one decent meal—to lessen the restavèk problem, a symptom not of Haitian cultural uniqueness, but of poverty and inequality.

  The militarization of aid is an equally complex topic. “Consider how,” Gourevitch continues, “in Ethiopia and Somalia during the nineteen-eighties and nineties, politically instigated, localized famines attracted the food aid that allowed governments to feed their own armies while they either destroyed or displaced targeted population groups.”56 Since 1995, Haiti has had no army. Its dissolution was not mourned by many: as the citizenry and historians know, the modern Haitian army was created during the U.S. occupation by an act of Congress. It never faced a non-Haitian enemy. Dissolving it as a body did not remove the army as a political risk, however, as was clear in the years leading up to 2004, when the elected government was dislodged by a violent process still willfully misunderstood in spite of abundant proof that weapons and other material were supplied to former soldiers massed on the Dominican border. 57 Among the effects of the 2004 coup was, predictably enough, the further weakening of the public sector.

  But few of those working in Haiti after the quake mistake these struggles over the control of the state apparatus with the logistic help provided by the U.S. military and others, a topic discussed in this book by Louise Ivers and others. When we start conflating the help offered by the USNS Comfort with struggles to topple sovereign governments, we have lost the gift of discernment.

  The century-old National Palace, destroyed in the earthquake (as was almost all other federal infrastructure)

  Injured boys in wheelbarrows at the General Hospital

  President Clinton and Nancy Dorsinville at the General Hospital, January 2010

  The nursing school in Port-au-Prince

  Injured man in tent clinic outside the General Hospital

  Tent clinic outside the General Hospital, five days after quake

  Dr. Louise Ivers at Parc Jean-Marie Vincent

  Patient being evacuated from Saint-Marc to the USNS Comfort

  Dr. Alix Lassègue, Director, and Marlaine Thompson, Chief of Nursing, with Harvard medical resident, Dr. Natasha Archer, at the General Hospital

  BELOW: The USNS Comfort, the U.S. Navy floating hospital, steamed into Haitian waters on day 8 after the earthquake

  Marlaine Thompson, Chief of Nursing at the General Hospital, with Loune Viaud, Director of Strategic Planning and Operations for Zanmi Lasante

  Dr. Dubique Kobel providing primary care services in Parc Jean-Marie Vincent, where 50,000 people were living in February 2010

  Dr. Evan Lyon with patient at the General Hospital

  Children in Parc Jean-Marie Vincent, March 2010; 1.3 million were living in similar conditions throughout the quake zone

  Didi Bertrand Farmer speaking with a woman in camp Carradeux (3,500 people, 680 families, 1 water source, 7 latrines), July 2010

  Naomi Rosenberg from Partners In Health’s Right to Health Care Program with quake-affected patients, Philadelphia, March 2010

  Shelove Julmiste in rehabilitation, Hôpital Albert Schweitzer

  Loune Viaud and baby Rose at Zanmi Beni. (“I have a dream for every one of them.”)

  The caregivers and children at Zanmi Beni, November 2010

  Dr. David Walton at the Mirebalais hospital construction site, January 2011

  Dr. Paul and Dr. Christophe with Roseleine after treatment, Lascahobas, January 2011

  A cholera patient receiving intravenous fluids, Lascahobas

  8.

  LOOKING FORWARD WHILE LOOKING BACK

  Lessons from Rwanda

  To advance a process of discernment is one of the only reasons to publish a book like this one, written as events continue to unfold. It’s difficult amid such suffering to find hopeful and relevant examples of building back better. But Rwanda offers more than a glimmer of hope, and we have more years of perspective with which to render judgments about central Africa. The legacies of colonialism and failed humanitarianism are still evident there as they are in Haiti.1 When Philip Gourevitch (following Linda Polman, Fiona Terry, and others2) asks us to consider “how, in the mid-nineties, fugitive Rwandan génocidaires were succored in the same way by international humanitarians in border camps in eastern Congo, so that they have been able to continue their campaigns of extermination and rape to this day,”3 he is making a claim of causality regarding the disastrous consequences of a series of decisions made far from the scenes of suffering witnessed in the Congo.4 Crossing the Rwanda-Congo border to Goma offers a lesson in contrasts: On one side of the frontier are Rwandan resettlement towns and planned villages, called imidugudu. On the other side, many of Goma’s buildings are partly buried in the hardened lava that poured forth from the giant Nyiragongo volcano in 1977 and again, more apocalyptically, in 2002. The Congolese side remains vulnerable to the raids of armed bands comprised of some of the same people who fled these camps when Rwandan forces finally invaded in 1996. This is the wild, wild east of Congo: almost as crowded as Rwanda, straddling the same volcanic hills, but immeasurably more lawless.

  What makes the difference? One answer is circular: the Rwandan side of the border has more security. Other assessments note a heavy Rwandan hand in recent extractive endeavors in the Congo. Another reason, and one with more lessons for Haiti, is a rationally planned development strategy directed by the Rwandan government. Rwanda remains a political flashpoint in international circles, generating almost as many discrepant views as Haiti. But its renaissance is increasingly recognized as an example of building back better. In 1996, two years after the genocide, Rwanda was still strewn with mass graves. With a million dead and two million recently repatriated refugees, it still ranked among the poorest countries in the world.5 Although Kigali’s infrastructure escaped major damage during the civil war and genocide, it was then a small city without the capacity to welcome even a fraction of the returnees. Many development experts were happy to write off Rwanda as a lost cause: the next in a long line of failed states doomed to ongoing conflict and underdevelopment.

  Fifteen years later, Rwanda has been transformed. If, as Jared Diamond has suggested, the collapse of Haiti and Rwanda were rooted in desperate competition for scarce resources, it’s worth noting that Rwanda by 2000 was no less crowded and cramped than before the genocide.6 But the strife within its borders had lessened even before the wheels of economic growth started turning. I’d like to consider some of the poli
cies that may have led to this upward trajectory—some of them surely relevant to Haiti’s own rebuilding challenges.

  In many ways, post-genocide Rwanda looked much like Haiti: a mountainous and densely populated country with high birth rates, intransigent poverty and consequent health problems, a history of post-colonial social strife (albeit shorter than Haiti’s), weak or discredited public institutions, low levels of literacy, and scant formal employment. The parallels should not be taken too far, however, because in other ways the countries diverge. No significant ethnic division haunts Haiti (although some remnants of European racial hierarchies are alive there to this day); Haiti is not packed with génocidaires and the families of their victims. Nonetheless, the similarities warrant a closer look.

  Over the five or so years after the genocide, the transitional government of Rwanda—led by Paul Kagame, the former leader of the Rwandan Patriotic Front whose military campaign is widely credited with ending the violence in 1994, at least within Rwandan borders—honed a development plan, later named Vision 2020.7 The plan called for investments in agriculture, infrastructure, and private enterprise; it laid out targets for the health and education systems, and for decentralization and coordination of development assistance. Vision 2020 also called for an end to dependence on foreign assistance by that year. The plan did not reject such aid—two decades is a long time for a proposed divorce—but rather stressed sovereignty as a precondition to long-term reconstruction and growth. But rebuilding the country’s institutions could not start in earnest until the massive numbers of repatriated refugees were resettled, even as the guilty among them were brought to justice. And each of these steps to recovery required a modicum of security in the broadest sense of the word.