by Paul Farmer
Although these compelling stories of “building back better” have received significant media attention, we cannot forget the hundreds of thousands of other Haitians who quietly face their predicament with determination and fortitude.
The truth is that “building back better” is not easy. The process takes time and involves setbacks and frustration. Impatience is growing. Earthquake survivors are still living in tents while cholera has gripped the nation, killing tens of thousands. But a natural disaster is not a moment; it’s a tragedy that unfolds over many months. It took seven years for Japan to rebuild after the 1995 Kobe earthquake. In the United States, those still displaced by Hurricane Katrina provide a stark reminder of how even the richest nations take years to recover from a natural disaster. The extent of the damage caused by the recent 9.0 earthquake and tsunami in Japan is still unclear. Yet in Haiti, in less than thirty minutes, an estimated 222,570 people died and an additional 300,572 were injured. This natural disaster may be the worst in recent history. The challenges ahead seem daunting, but we cannot escape one truth: The survivors of the quake deserve to have their country rebuilt as they dream it to be, not as it once was.
NOTES
Chapter 1
1 R. Yates. “Universal health care and the removal of user fees.” Lancet 373 (2009): 2078–2081.
2 Such anxieties were warranted: there were at least fifty-two aftershocks of magnitude 4.5 or greater in the two weeks after the quake. See Mike Melia, Jonathan Katz, and Michelle Faul. As Haiti Mourns, Quake Survivor Found in Rubble. Associated Press: January 24, 2010. Available: http://savannahnow.com /latestnews/2010-01-24/haiti-mourns-quake-survivor-found-rubble (accessed April 15, 2011).
3 See Rudy Roberts. “Responding in a Crisis: The Role of National and International Health Workers—Lessons from Haiti.” Merlin: London (August 2010).
4 Mobile Army surgical hospital (MASH) units are field-ready medical tents containing emergency medical equipment, oxygen, electrical generators, and other supplies; they are deployed by the military during disasters and other medical emergencies. Many of us hoped that MASH units might be leveraged to strengthen health systems in disaster zones, leaving behind more robust surgical capacity.
5 For more details about the USNS Comfort, see http://www.navy.mil/search/display.asp?story_id=50653 (accessed April 15, 2011).
6 In her chapter, “Humanitarian Aid, Impartiality, and Dirty Boots,” Louise Ivers considers the role of the U.S. military in the immediate earthquake response in more detail. For coverage in the media, see “Haiti Earthquake: Confusion at Airport Hampers Aid Effort.” Telegraph: January 18, 2010. Available: http://www.telegraph.co.uk/news/worldnews/centralamericaandthecaribbean/haiti/7016051/Haiti-earthquake-confusion-at-airport-hampers-aid-effort.html (accessed April 15, 2011).
7 Cange is a former squatter settlement in central Haiti where Partners In Health first began working about twenty-five year ago. In a previous book, in keeping with conventions in anthropology, I changed the name to “Do Kay” in writing about its early history. See Paul Farmer. AIDS and Accusation: Haiti and the Geography of Blame. (Berkeley: University of California Press, 1992). Chapter 3, “January 12 and the Aftermath,” considers its role in the aftermath of the earthquake as a referral facility for overcrowded urban hospitals and clinics that encountered the brunt of the patient load. Cange took in hundreds of quake victims in need of surgery, and later, rehabilitation.
8 Some have argued persuasively that palliation of pain ought to be considered a basic human right; this young woman’s story, and the stories of so many quake victims we’ve seen in the last year, renders vivid the need for such an entitlement. See, for example, J. Stjernswärd et al. “The Public Health Strategy for Palliative Care.” Journal of Pain and Symptom Management 33 (May 2007): 486–493; E. L. Krakauer et al. “Opioid Inaccessibility and Its Human Consequences: Reports from the Field.” Journal of Pain and Palliative Care Pharmacotherapy 24 (2010): 239–243; F. Brennan. “Palliative Care as an International Human Right.” Journal of Pain and Symptom Management 33 (May 2007): 494–499.
9 The devastation caused by the earthquake led many to think about what theologians call theodicy: how to explain the existence of grotesque suffering while still believing in goodness and dignity. In speaking about the Haitian earthquake, how could this level of extreme suffering be explained or justified among a people who had already suffered so much? There was no shortage of commentary on this score. Pat Robertson, a Southern Baptist televangelist, offered the following explanation: Haitians “were under the heel of the French, you know Napoleon the 3rd and whatever, and they got together and swore a pact to the Devil.” (See “Pat Robertson Blames Earthquake on Pact Haitians Made with Satan.” ABC News: January 12, 2010. Available: http://blogs.abcnews.com./politicalpunch/2010/01/patrobertson-blames-earthquake-on-pact-haitians-made-with-satan html). (I was in Haiti at this time, and didn’t even note his comment but had the great privilege of working with Operation Blessing International, a humanitarian organization associated with Robertson. As much as I disagree with his theodicy, all I can say is that this organization was one of the very finest, and best led, we worked with in the year after the quake.) As noted, another more humble sort of theodicy comes from medicine: the January 12 earthquake as an “acute-on-chronic” event. This temblor wreaked havoc because adverse social conditions and extreme ecological fragility primed Port-au-Prince for massive loss of life and destruction when the ground began shaking on January 12. This topic will be explored throughout this book.
10 For more discussion on the provision of surgical care in Haiti (and reflection on the harmful consequences of a fee-for-service health care financing model in the context of care there), see L. C. Ivers et al. “Increasing Access to Surgical Services for the Poor in Rural Haiti: Surgery as a Public Good for Public Health.” World Journal of Surgery 32, no. 4 (2008): 537–542.
Chapter 2
1 Haiti-Katrina parallels are discussed in a short essay, “From Gonaïves to New Orleans” (available: http://www.pih.org/news/entry/from-gonaives-to-neworleans/, accessed April 15, 2011). It highlights the social forces that influence disasters natural and unnatural: “Disasters are never wholly and purely ‘natural,’ as the residents of New Orleans and dismayed onlookers have discovered. How can we pretend that racism, a social disaster, played no role in the aftermath of Katrina? . . . There are many reasons Jeanne, a slow-moving tropical storm with relatively low wind speeds, caused such devastation in a country it never even crossed, and those reasons are social. And just as those left behind in New Orleans had to suffer humiliation and uncertainty, in spite of the valiant efforts of many (including some of our own supporters), so too did Jeanne’s survivors.” As the huge toll taken in Haiti by Jeanne came to light, journalists arrived to cover the story and, again, the story will sound familiar to those following Katrina. CNN reported that UN peacekeepers, in place since the violent overthrow of Haiti’s elected government, “fired into the air to keep a hungry crowd at bay” and “fired smoke grenades as crowds of Haitian flood victims tried to break into a food distribution site.” The relief workers themselves, it seems, were in need of relief: “As they waited for days, one woman yelled at a Red Cross worker on the balcony of City Hall ‘Help me. I’m hungry.’ The Red Cross volunteer yelled back ‘I’m hungry, too.’” It’s no wonder that New Orleans’ and Haiti’s disasters sound similar.Many Americans have forgotten that the Louisiana Purchase was the direct result of Napoleon’s defeat at the hands of the Haitians in 1804. Haitian President Jean-Bertrand Aristide, in exile in South Africa, made reference to this history in a condolence note made public recently: “The connection [between Haiti and Louisiana] . . . finds new root in a shared human suffering caused by this week’s catastrophic storm and ensuing floods.” Others have explored the extent to which no disaster is simply “natural.” See, for example, Neil Smith, “There’s No Such Thing as a Natural Disaster.” Social Science Research Council, June 2006 (available: h
ttp://understandingkatrina.ssrc.org /accessed April 15, 2011) and E. Klinenberg. “Denaturalizing Disaster: A Social Autopsy of the 1995 Chicago Heat Wave.” Theory and Society 28 (April 1999): 239–295. Two of my former students are now publishing a moving account of an unnatural disaster—the collapse of a dam in Gujarat, India that leveled the city of Morbi in 1979. See Utpal Sandesara and Thomas Wooten. No One Had a Tongue to Speak. (New York: Prometheus Books, 2011).
2 For example, see P. Farmer et al. “The dilemma of MDRTB in the global era.” International Journal of Tuberculosis and Lung Disease 2, 11 (1998): 869–876; P. Farmer. Infections and Inequalities: The Modern Plagues (Berkeley: University of California Press, 1999), especially chapters 7–9, pp. 184–261.
3 My colleagues and I have explored these and other epidemics in several studies in books, including The Global Impact of Drug-Resistant Tuberculosis (Harvard Medical School/Open Society Institute, 1999), Paul Farmer. Pathologies of Power: Health, Human Rights, and the New War of the Poor (Berkeley: University of California Press, 2005); Farmer, Infections and Inequalities.
4 S. S. Shin et al. “Treatment Outcomes in an Integrated Civilian and Prison MDR-TB Treatment Program in Russia.” International Journal of Tuberculosis and Lung Disease 10 (2006): 402–408.
5 P. Farmer et al. “Community-based Approaches to HIV Treatment in Resource-poor Settings.” Lancet 358 (2001): 404–409.
6 Sachs is an outspoken champion of poverty reduction. In The End of Poverty: Economic Possibilities for Our Time (New York: Penguin, 2005), he argues that a series of “traps” linked to poverty keep poor people from amassing enough capital to save and invest; they are thereby unable to reach the first rung of development. We’re working with an economist, Matt Bonds, who has been helping us study the impact of efforts to spring poverty traps in rural Rwanda. See, for example, M. Plucinski, C. N. Ngonghala, and M. H. Bonds. “Stochasticity and Safety Nets Imply Lower Barriers for Breaking Disease-Driven Poverty Traps.” Journal of the Royal Society Interface: under revision (2011); and M. H. Bonds, D. C. Keenan, P. Rohani, and J. D. Sachs. “Poverty Trap Formed by the Ecology of Infectious Diseases.” Proceedings of the Royal Society, Series B 277 (2010): 1185–1192. [Royal Society, Series B 277.] See also Sachs’ book Common Wealth: Economics for a Crowded Planet (New York: Penguin, 2008), which considers the growing risks caused by global forces such as climate change, population growth, and poverty. What were once issues of moral concern now pose immediate security threats, Sachs argues. “When a country is too poor to provide its people with basic necessities such as health care,” he writes, “and when the underlying ecology makes agriculture difficult without fertilizer and irrigation, any change can push society off the edge and into outright desperation.… Something as simple as bad rains can trigger internal conflicts when a society is living on the edge of survival.” (Sachs, 2008, pp. 278–279.)
7 See “Consensus Statement on Antiretroviral Treatment for AIDS in Poor Countries.” March 2001. Available: http://www.cid.harvard.edu/cidinthenews/pr/consensus_aids_therapy.pdf (accessed April 15, 2011).
8 D. Walton et al. “Integrated HIV Prevention and Care Strengthens Primary Health Care: Lessons from Rural Haiti.” Journal of Public Health Policy 25, no. 2 (2004): 137–158.
9 For more on the collaborations that led to the foundation of l’Université de la Foundation Aristide, see “A New Generation of Doctors.” Partners In Health Bulletin (Summer 2003). Available: http://parthealth.3cdn.net /77b68ed0fa3597528f_qpm6b5bie.pdf(accessed April 15, 2011). It’s my hope that we will be able to revive this effort in the future because the need has never been greater than now.
10 See, for example, P. Farmer. “Political Violence and Public Health in Haiti.” New England Journal of Medicine 350 (2004): 1483–1486; Farmer. Pathologies of Power, especially “Preface to the Paperback Edition,” p. xxi; Paul Farmer. The Uses of Haiti (Monroe, ME: Common Courage Press, 2006), p. 376.
11 Cyril Mychalejko. “Lawlessness, Kidnappings, and Murder in Haiti.” Upside Down World: July 26, 2006. Available: http://upsidedownworld.org /main/news-briefs-archives-68/372-lawlessness-kidnappings-and-murder-in-haiti (accessed April 15, 2011).
12 Azadeh Ansari and Reynolds Wolf. “An Unusually Destructive Hurricane Season Ends.” CNN: December 1, 2008. Available: http://www.cnn.com/2008/U.S./11/30/hurricane.season.ends/index.html (accessed April 15, 2011); Matthew Weaver. “Hurricane Ike Forces Mass Evacuation in Cuba.” Guardian (September 9, 2008). Available: http://www.guardian.co.uk/world/2008/sep/09/cuba.cuba (accessed April 15, 2011).
13 The transcript of the letter is available online at http://www.pih.org/news/entry/i-have-never-seen-anything-as-painful-paul-farmer-writes.
14 See Chapter 3 “January 12 and the Aftermath,” note 2 and also p. 55.
15 P. Farmer. AIDS and Accusation: Haiti and the Geography of Blame (Berkeley: University of California Press, 1992), pp. 186–190.
16 Galeano notes that real coffee plantation wages in Haiti ranged from $.07 to $.15 a day. See Eduardo Galeano. Open Veins of Latin America: Five Centuries of the Pillage of a Continent (London: Monthly Review Press, 1971), p. 98. Since 2006, the Préval administration raised the minimum wage in nongarment sectors to $5 per day (eight hours). For clothes to be exported to the United States, however, workers can be paid about $3 per day. Both the $3 and $5 rate have triggered outrage—from opposite positions—within Haiti and without. See, for example, Robert Naiman. “Haitian Garment Workers Should Get at Least $5 a Day.” Huffington Post (February 23, 2010). Available: http://www.huffingtonpost.coml/robert-naiman/haitian-garment-workers-s_b_473262.htm (accessed April 15, 2011). The story is so old that I was able to write a well-honed (but less well-researched) article about the topic in 1988: “Blood, Sweat, and Baseballs: Haiti in the West Atlantic System.” Dialectical Anthropology 13, no. 1 (1988): 83–99.
17 See Chapter 6 “From Relief to Reconstruction,” p. 152.
18 Paul Farmer. “Haiti’s unnatural disaster.” The Nation: September 17, 2008. Available: http://www.thenation.com/article/haitis-unnatural-disaster (accessed April 15, 2011).
19 See, for example, James Smith. “Public Health Crusader Could Join Obama Team.” Boston Globe (May 14, 2009). Available: http://www.boston.com/news/politics/politicalintelligence/2009/05/public_health_c.html (accessed April 15, 2011).
20 Trenton Daniel. “UN’s Deputy Special Envoy to Haiti Wraps up First Trip.” Miami Herald: September 9, 2010. Available: http://missionmanna.wordpress.com/2009/09 (accessed April 15, 2011). I didn’t use my special red UN passport often after this trip because when I returned to Miami, the immigration official who scanned the passport was unimpressed. When he swiped it, the officer gave me a quizzical look. “What does it say?,” I asked. “Nationality invalid,” he replied.
21 Some with disaster management experience include victims’ sentiments (including complaint) in their analysis and strategy. “Do not underestimate the emotion that confronts innocent victims of any disaster . . . You have to deal with those,” said Kenneth Feinberg after the BP oil spill in the summer of 2010. See Martha Moore. “Man at Helm of Oil Fund Master of Mediation.” USA Today: June 27, 2010. Available: http://www.usatoday.com/news/nation/2010-06-27-Feinberg_N.htm. Some of Feinberg’s success in guiding policy after the spill, including legal settlements such as the 9/11 Compensation Fund and the BP Fund, comes from the attention paid to the ire that victims feel when forces beyond their control deprive them of compensation and resolution. A failure to honor such sentiments tends to weaken legal resolutions.
22 The point was made by Mildred Aristide in her excellent book on the topic, L’Enfant En Domesticité en Haïti: Produit d’un Fossé Historique (Port-au-Prince, Haiti: Imprimerie H. Deschamps, 2003), pp. 89–90: “It is clear that Haiti’s rural development and the faltering road to a national public education system have been and remain at the center of the propagation of child domestic service in the country. This explains why the prototypical image of a child in domestic servi
ce is one of a child from the impoverished countryside seeking an education, working in the city.”
23 Timothy T. Schwartz. Travesty in Haiti: A True Account of Christian Missions, Orphanages, Food Aid, Fraud and Drug Trafficking (Self-published, 2008), p. 66.
24 For more information on the construction of the bridge to Boucan Carré, see Partners In Health’s September 2009 online bulletin, available: http://www.pih.org/pages/pih-e-bulletin-2009-09 (accessed April 15, 2011). Also see a short documentary clip in which Dr. Louise Ivers discusses the importance of the bridge, available here: http://www.pih.org/pages/service/ (accessed April 15, 2011).
25 Ophelia Dahl. “Thomas J. White Symposium 2009 Remarks.” October 3, 2009.
26 The hatchery had been designed by charismatic and talented Ivoirien agronomist Valentin Abe, whose work is mentioned in Jéhane Sedky’s essay “Building Back Better.”
27 The baby was named Rolando in honor of our guest.
28 For more about the conference, along with a critique of donor activity in Haiti, see Robert Maguire’s briefing for the United States Institute for Peace (Special Report 232, September 2009). Available: http://www.usip.org/files/resources/haiti_after_donors_conference.pdf (accessed April 15, 2011). “The state’s lack of capacity to render public services,” Maguire argues, “has resulted in the virtual absence of the government as a positive presence in citizen’s lives, thus stoking citizen frustration and weakening the democratic process. Donor support of nonstate entities has created an environment that lacks coherence, particularly in support of national development plans.”