by Paul Farmer
14 Jonathan Katz. “UN Worries Its Troops Caused Cholera in Haiti.” Associated Press (November 20, 2010). Available: http://www.msnbc.msn.com/id/40280944/ns/health/ (accessed April 15, 2011).
15 Ibid.
16 Some took this to mean that the peacekeepers could not be cholera’s source. But this view does not take into account the frequency of asymptomatic cholera cases as well as false negatives. Katz goes on to explain: “The tests were taken from leaking water and an underground waste container at the base a week after the epidemic was first noted and processed at a lab in the neighboring Dominican Republic, UN spokesman Vincenzo Pugliese said. Mekalanos said that it is extremely difficult to accurately isolate cholera in environmental samples and that false negatives are common. The Nepalese troops were not tested for cholera before their deployment if they did not present symptoms. But health officials say 75 percent of people infected with cholera bacteria do not show symptoms and can still pass on the disease for weeks.” Katz. “UN Worries Its Troops Caused Cholera in Haiti.”
17 World Health Organization. “Cholera Vaccines: WHO Position Paper.” Wkly Epidemiol Rec 85 (2010): 118.
18 Ivan Watson. “Medical Group Blasts ‘Inadequate’ Response to Haiti Cholera Outbreak.” CNN (November 19, 2010). Available: http://articles.cnn.com:/2010-11-19/world/haiti.cholera_1_haiti-cholera-outbreak-peacekeepers-nepal?_s=PM WORLD (accessed April 15, 2011).
19 Ibid.
20 Katz. “UN Worries Its Troops Caused Cholera in Haiti.”
21 Watson. “Medical Group Blasts ‘Inadequate’ Response to Haiti Cholera Outbreak.”
22 C. S. Chin et al. “The Origin of the Haitian Cholera Outbreak Strain.” New England Journal of Medicine 164 (2011): 1.
23 See, for example, Richard Knox. “Cholera Vaccine Isn’t the Answer for Haiti.” NPR (October 28, 2010). Available: http://www.npr.org/blogs/health/2010/10/28/130884642/why-the-cholera-vaccine-isn-t-the-answer-for-haiti (accessed April 15, 2011).
24 U.S. Centers for Disease Control and Prevention. Update: cholera outbreak—Haiti 2010. (December 8, 2010). Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5948a4.htm (accessed April 15, 2011).
25 See Partners In Health. “Curbing Cervical Cancer in Haiti.” Partners In Health Bulletin (August 27, 2010). Available: http://www.pih.org/news/entry/curbing-cervical-cancer-in-haiti/ (accessed April 15, 2011).
26 A project at the National Penitentiary of Port-au-Prince found that providing antibiotics (along with potable water, soap, and sanitation services) to prisoners sharing living quarters with others with confirmed cholera helped to reduce incidence within the institution. See May J., Joseph P., Pape J., Binswanger I. “Healthcare for Prisoners in Haiti,” Ann Intern Med. 153 (2010): 407–410.
27 Jeff Sachs. “The Fire This Time Was US-Fueled.” Taipei Times (March 1, 2009). Available: http://www.taipeitimes.com/News/editorials/archives/2004/03/01/2003100742/3 (accessed April 15, 2011).
28 Ingrid Arnesen and Betsey Mckay. “Cholera Spreading in Haiti Faster than Thought.” Wall Street Journal (November 25, 2010). Available: http://online.wsj.com /article/SB10001424052748703572404575635533532154818.html (accessed April 15, 2011).
29 Some studies also indicate that the proportion of severe cases may be underestimated in El Tor epidemics. See, for example, K. Bart et al. “Seroepidemiologic Studies During a Simultaneous Epidemic of Infection with El Tor Ogawa and Classical Inaba Vibrio cholerae.” Journal of Infectious Diseases 121 (1970): 17–24. This paper compares the spectrum of illness for El Tor and classic biotype strains of Vibrio cholerae. The classic biotype produced a lower proportion of asymptomatic infections (59% vs. 75%) and a higher proportion of severe infections (11% vs. 2%) than the El Tor biotype. Some have hypothesized that the spectrum of variant El Tor biotype strains with classic toxin type would more closely resemble that of the classic biotype, though evidence is anecdotal to date.
30 See L. Ivers et al. “Five Complementary Interventions to Slow Cholera: Haiti.” Lancet 376 (2010): 2048–2051; D. Walton and L. Ivers. “Responding to Cholera in Post-Earthquake Haiti.” New England Journal of Medicine 364 (2011): 3–5, published online on December 9, 2010.
31 Don McNeil. “Use of Cholera Vaccine in Haiti Is Now Viewed as Viable.” New York Times (December 10, 2010).
32 Ibid.
33 Paul Farmer and Jean-Renold Réjouit. “How We Can Stop Cholera in Haiti.” Newsweek (November 20, 2010).
34 In Press: PLoS Neglected Tropical Diseases: e1145. (2011) doi: 10.1371/ journal.pntd.0001145
35 OCHA Cholera Situation Report # 33 (January 21, 2011). Available: http://www.reliefweb.int/rw/rwb.nsf/db900SID/MCOI-8DDCXY?OpenDocument (accessed April 15, 2011).
36 R. Tuite et al. “Cholera Epidemic in Haiti, 2010: Using a Transmission Model to Explain Spatial Spread of Disease and Identify Optimal Control Interventions.” Annals of Internal Medicine (March 7, 2011).
37 J. Andrews et al. “Transmission Dynamics and Control of Cholera in Haiti: An Epidemic Model.” Lancet (March 16, 2011), DOI: 10.1016/S0140-6736(11)60273-0.
38 Unni Karunakara. “Haiti: Where AidFailed.” Guardian (December 28, 2010). Available: http://www.guardian.co.uk/commentisfree/2010/dec/28/haiti-choleraearthquake-aid-agencies-failure (accessed April 15, 2011).
39 Jonathan Katz. “Six Killed in Sept. 24 Rainstorm in Port-au-Prince.” Associated Press (September 24, 2010). Available: http://canadahaitiaction.ca /content/six-killed-sept-24-rainstorm-port-au-prince (accessed April 15, 2011).
40 For a summary of Kouchner’s trip to Haiti, see “Visit of Bernard Kouchner to Haïti (September 25 and 26, 2010).” Diplomatie (September 26, 2010). Available: http://www.diplomatie.gouv.fr/en/country-files_156/haiti_473/france-andhaiti_2641/political-relations_6180/visit-of-bernard-kouchner-to-haiti-25-26.09.10_14309.html (accessed April 15, 2011).
41 Deborah Sontag. “In Haiti, Rising Call for Displaced to Go Away.” New York Times (October 4, 2010). Available: http://www.nytimes.com/2010/10/05/world/americas/05haiti.html (accessed April 15, 2011).
42 There are other reminders, too. In an article titled “Haiti: Humanitarian Crisis or Crisis of Humanitarianism,” Jane Regan points out that a few days before Hurricane Tomas hit the island on November 5, Port-au-Prince’s canals—critical drainage arteries—had not yet been cleared. Huffington Post (November 5, 2010). Available: http://www.huffingtonpost.com/jane-regan/haiti---humanitarian-cris_b_779503.html.
43 Jonathan Katz and Martha Mendoza. “Haiti Still Waiting for Pledged U.S. Aid.” Associated Press (September 29, 2010). Available: http://www.huffingtonpost.com/2010/09/29/haiti-still-waiting-for-p_n_743002.html (accessed April 15, 2011).
44 See Ma. Rizza Leonzon. “Bureaucracy Delays US Aid for Haiti Reconstruction.” Devex (September 29, 2010). Available: http://www.devex.com/en/blogs/the-development-newswire/us-aid-pledge-for-haiti-stalled-by-bureaucray-ap-says (accessed April 15, 2011). See also Jonathan Katz and Martha Mendoza. “Another Obstacle Stalls $1.15 Billion in U.S. Aid to Haiti.” Associated Press (November 6, 2010). Available: http://finance.yahoo.com/news/Another-obstacle-stalls-115B-apf-3649074743. html?x=0 (accessed April 15, 2011). A number of Republican senators, led by Tom Coburn of Oklahoma, raised concerns about corruption, stalling the money for months. The authors report, “President Barack Obama wasn’t able to sign the appropriations bill containing the money until July 29. A subsequent bill to authorize release of the funds stalled, and it took until September 20 for the Obama administration to submit a spending plan in an attempt to free up the money.”
45 Katz and Mendoza. “Haiti Still Waiting for Pledged U.S. Aid.”
46 Martha Brannigan and Jacqueline Charles. “US Firms Want Part in Haiti Cleanup.” Associated Press (February 9, 2010). Available: http://www.truthout.org/us-firms-want-part-haiti-cleanup56775. (accessed April 15, 2011). Competing for roles like these was, of course, unseemly for universities. Whether speaking of a Harvard doctor helping a colleague from Dartmouth perform, with Haitian colleagues, the firs
t dialysis in a town in central Haiti or an American plastic surgeon addressing complex surgical problems in a quake-affected hospital, there was purity of purpose for the American research university. Whether it was a group of students and faculty coordinating volunteers and planes and helping to transfer patients, or students and other university-affiliated groups willing to raise money for relief and reconstruction, it was evident that universities had much to offer even before we got to the in-kind donations of research and teaching that we are uniquely qualified to offer. The alternative was to curry favor with power qua power, with the sort of results laid out so clearly in The Best and the Brightest. Halberstam mentioned the story of how, in 1967, a leader of the Urban League “defended the war and ended up in a bitter confrontation with Dr. King; [Whitney] Young told King his criticism of the war was unwise, it would antagonize the President and they wouldn’t get anything from him. King, genuinely angry, told him, ‘Whitney, what you’re saying may get you a foundation grant, but it won’t get you into the kingdom of truth.’” (David Halberstam. The Best and the Brightest, p. 185.) It wasn’t as if we didn’t need foundation grants to respond effectively to the sorts of problems we encountered in Haiti. But we didn’t need to sell our souls to get them.
47 Trenton Daniel. “Bill Clinton Tells Diaspora: ‘Haiti Needs You Now.’” Miami Herald (August 9, 2009). Available: http://www.miamiherald.com/news/americas/haiti/story/1179067.html.
48 Even the U.S. Government Accounting Office, an independent evaluative body, long ago reached dim conclusions about the effectiveness of our government’s programs. It concluded: “The aid program to date has had limited impact on Haiti’s dire poverty, and many projects have had less than satisfactory results.” See U.S. General Accounting Office. GAO Report-Assistance to Haiti: Barriers, Recent Program Changes and Future Options (1982). Available: http://archive.gao.gov/d41t14/117663.pdf (accessed April 15, 2011).
49 The “late Victorian holocausts” resulted in fifty million deaths, leading Davis to the conclusion that “we are not dealing, in other words, with ‘lands of famine’ becalmed in stagnant backwaters of world history, but with the fate of tropical humanity at the precise moment (1870–1914) when its labor and products were being dynamically conscripted into a London-centered world economy. Millions died, not outside the ‘modern world system,’ but in the very process of being forcibly incorporated into its economic and political structures.” Mike Davis. Late Victorian Holocausts: El Nino Famines and the Making of the Third World (London: Verso, 2001), p. 9. See also Amartya Sen’s analysis of why no famine has occurred in a functioning democracy. “Any government that is accountable to its citizens,” he writes, “can without great difficulty ration food provisions and prevent death by starvation; famines occur, instead, in states without the will to provide services for their citizens.” Amartya Sen. Poverty and Famines: An Essay on Entitlement and Deprivation (London: Oxford University Press, 1981).
50 Nor could other poor countries. The rich world pays out an estimated $300 billion in annual agribusiness subsidies, while preventing poor countries from doing the same under the banner of free trade. (See “The White Man’s Shame.” The Economist, September 25, 1999: p. 89.) Tariffs, which are on average four times higher in rich countries, are disbanded in poor countries, and subsidized crops are sold at artificially low prices, making agriculture unprofitable across much of the developing world. This also fuels erosion, deforestation, and urbanization, along with poverty and inequality. See Thomas Pogge. World Poverty and Human Rights (Cambridge, UK: Polity Press, 2008), pp. 15–22.
51 Polman. The Crisis Caravan: What’s Wrong with Humanitarian Aid?, p. 39.
52 Mark Danner. “To heal Haiti look to history, not nature.” New York Times (January 21, 2010). Available: http://www.nytimes.com/2010/01/22/opinion/22danner.html?_r=2&pagewanted=all (accessed April 15, 2011).
53 Philip Gourevitch. “Alms Dealers: Can You Provide Humanitarian Aid without Facilitating Conflicts?” The New Yorker (October 11, 2010). Available: http://www.newyorker.com/arts/critics/atlarge/2010/10/11/101011crat_atlarge_gourevitch (accessed April 15, 2011), p. 105.
54 Two other accounts Gourevitch mentions of the unintended consequences of humanitarian aid are Michael Maren’s The Road to Hell: The Ravaging Effects of Foreign Aid and International Charity (New York: Simon & Schuster, 1997), and Alex de Waal’s Famine Crimes: Politics and the Disaster Relief Industry in Africa (Bloomington, IN: Indiana University Press, 1997).
55 On restavèks, Mildred Aristide’s 2003 book Child Domestic Service in Haiti and Its Historical Underpinnings underlines this link. Border conflicts occupy a large place in the Gourevitch-Polman litany, from Haiti-D.R. to Rwanda-Zaire to Cambodia-Thailand. “Consider how, in the early eighties, aid fortified fugitive Khmer Rouge killers in camps on the Thai-Cambodian border,” Gourevitch writes, “enabling them to visit another ten years of war, terror, and misery upon Cambodians.” Gourevitch. “Alms Dealers,” p. 105.
56 Gourevitch. “Alms Dealers,” p. 105.
57 See the long exposé in the New York Times by Walt Bogdanich and Jenny Nordberg (2006), “Mixed U.S. Signals Help Tilt Haiti Toward Chaos.” One passage reads, “Haiti has had a long, tense relationship with the Dominican Republic, its more affluent neighbor on the island of Hispaniola. Haitians who work there are often mistreated, human rights groups say, and the country has been a haven for those accused of trying to overthrow Haitian governments. In December 2002, the I.R.I. began training Haitian political parties there, at the Hotel Santo Domingo, owned by the Fanjul family, which fled Cuba under Mr. Castro and now runs a giant sugar-cane business. The training was unusual for more than its location: only Mr. Aristide’s opponents, not members of his party, were invited.” Available: http://www.nytimes.com/2006/01/29/international/americas/29haiti.html?pagewanted=all (accessed April 15, 2011).
Chapter 8
1 Modern Haitian history surely also bears the imprint of the conquests and genocides visited upon the island between the close of the fifteenth century, when the Columbian exchange began to extinguish Haiti’s natives, and the late eighteenth century, when slavery made Haiti the largest source of prerevolutionary France’s foreign exchange and its most unstable colony. When Jared Diamond writes that “guns, germs, and steel” play, along with geography, the chief roles in determining why some regions are rich and others poor, he could find few examples more illustrative than the island of Hispaniola, especially its crowded and mountainous western portion; see Jared Diamond. Guns, Germs, and Steel: The Fates of Human Societies (New York: Norton, 1997), p. 213. “There is no doubt,” Diamond writes, “that Europeans developed a big advantage in weaponry, technology, and political organization over most of the non-European peoples that they conquered. But that advantage alone doesn’t fully explain how initially so few European immigrants came to supplant so much of the native population of the Americas and some other parts of the world. That might not have happened without Europe’s sinister gift to other continents—the germs evolving from Eurasians’ long intimacy with domestic animals.” Cholera may be the next chapter of this dark saga.
2 Reflecting on her experiences working for Médecins Sans Frontières in the Goma (Zaïre) refugee camps, Terry describes “the paradox of humanitarian action: it can contradict its fundamental purpose by prolonging the suffering it intends to alleviate.” See Fiona Terry. Condemned to Repeat? (Ithaca: Cornell University Press, 2002), p. 89.
3 Gourevitch. “Alms Dealers,” p. 105.
4 This book, written in the aftermath of an earthquake in Haiti does not seek to explore competing claims of causality regarding the violence in the Congo. For more on this topic, see the sometimes conflicting accounts by John Pottier (Re-imagining Rwanda: Conflict, Survival and Disinformation in the Late Twentieth Century [New York: Cambridge University Press, 2002]); Gérard Prunier (Africa’s World War: Congo, the Rwandan Genocide, and the Making of a Continental Catastrophe [Oxford: Oxford University Press, 2009]); and Jason
Stearns (Dancing in the Glory of Monsters: The Collapse of the Congo and the Great War of Africa [New York: PublicAffairs, 2011]), as well as the broader review of postcolonial African history by Martin Meredith (The Fate of Africa [New York: PublicAffairs, 2005]).
5 In 1996, Rwanda had a gross national income per capita of 730 (PPP international dollars). See the World Bank’s World Development Report 1996: From Plan to Market (New York: Oxford University Press, 1996).
6 Jared Diamond. Collapse: How Societies Choose to Fail or Succeed (New York: Viking, 2005). In Collapse, Diamond interprets the Rwandan genocide as, in part, a Malthusian crisis in which population growth outpaces food production. In the 1990s (and today), it was the most densely populated country in Africa and one of the most densely populated in the world. As trees were chopped down and land overused, disputes—often violent—over land became frequent in the years before the genocide. “Even before 1994,” Diamond writes, “Rwanda was experiencing rising levels of violence and theft, perpetrated especially by hungry landless young people without off-farm income. When one compares crime rates for people of age 21–25 among different parts of Rwanda, most of the regional differences prove to be correlated statistically with population density and per-capita availability of calories: high population densities and worse starvation were associated with more crime.” (Collapse, p. 324–325.) Competition over land and food were important factors, among others, in the lead up to the Rwandan civil war and genocide.Diamond brings a similar lens to a question this book considers as well: why have the fates of Haiti and the Dominican Republic—sharing a single island and once home to a single people—diverged dramatically in the last two centuries? (Diamond also notes the visible differences in forest cover across the border: the Dominican side is 28% forested; the Haitian side, 1%. See Collapse, p. 329.) His answer is complex and multifaceted, but he again calls the reader’s attention to the twin problems of population density and environmental strain: “France imported far more slaves into its colony than did Spain. As a result, Haiti had a population seven times higher than its neighbor during the colonial times, and it still has a somewhat larger population today, about 10,000,000 versus 8,800,000. But Haiti’s area is only slightly more than half of that of the Dominican Republic, so that Haiti with a large population and smaller area has double the Republic’s population density. The combination of that higher population density and lower rainfall was the main factor behind the more rapid deforestation and loss of soil fertility on the Haitian side.” (Collapse, p. 340.)