Haiti After the Earthquake (7 page)
Read Haiti After the Earthquake Online
Authors: Paul Farmer
I was still trying to think and write and teach about health and development. Any doctor practicing in Haiti knew very well that the country's refractory poverty, worsened each year by political instability, unfair trade policies, and environmental disasters, rendered our patients sick. In other words, large-scale forces beyond the traditional scope of clinical medicine were the chief drivers of illness and misfortune among the poor. The story was similar everywhere we worked, from Russia to Rwanda: our patients needed jobs. Most would have been happy with almost any kind of steady employment. The jobs we'd created over the years were mainly for community health workers. They had long been paid too little in part because of the social fiction, encouraged by influential economists and policy mandarins, that such workers should be unpaid “community health volunteers.” Development experts (themselves compensated) claimed it was not “sustainable” or cost-effective to pay community health workers.
For years, we'd encouraged medical students to listen to their patients. The more I listened to patients, the more I revised my views on the matter of jobs. In a book written almost two decades previously, I railed against the offshore assembly industry in Haiti, which, it had seemed then, did little more than exploit grotesque differentials in labor costs.
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In 1971, Eduardo Galeano noted “the wages Haiti requires by law belong in the department of science fiction,” and nothing that had happened there since changed my mind about the imperative of decent pay and better conditions for workers.
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But scores of Haitians were fleeing the depleted countryside, where we worked, for the Dominican Republic or the often-illusory promise of factory jobs in Port-au-Prince. Again, these forces, many of which originated far from Haitian soil, were beyond the control of those buffeted by them. President Clinton himself had publicly apologized for pushing legislation that undermined Haitian rice production: U.S. agricultural subsidies meant that Haitian farmers could not compete with U.S. agribusiness.
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Haiti, once the world's leading exporter of sugar, was also now a net importer of subsidized sugar from the United States and elsewhere.
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In 1971, Eduardo Galeano noted “the wages Haiti requires by law belong in the department of science fiction,” and nothing that had happened there since changed my mind about the imperative of decent pay and better conditions for workers.
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But scores of Haitians were fleeing the depleted countryside, where we worked, for the Dominican Republic or the often-illusory promise of factory jobs in Port-au-Prince. Again, these forces, many of which originated far from Haitian soil, were beyond the control of those buffeted by them. President Clinton himself had publicly apologized for pushing legislation that undermined Haitian rice production: U.S. agricultural subsidies meant that Haitian farmers could not compete with U.S. agribusiness.
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Haiti, once the world's leading exporter of sugar, was also now a net importer of subsidized sugar from the United States and elsewhere.
Haitian agriculture continued to be hammered by the forces of nature, by the punishingly unfair political economy (to use an oldschool term), and by the simple fact that few young Haitians wanted to work in a sector that offered diminishing returns. Those who did want to farm had no access to credit, good seeds, fertilizer, or the tools of their trade. Addressing these problems required massive pro-poor investments in agriculture, which would do more to alleviate Haitian poverty than fifty thousand new assembly jobs. But did development need to be a competition for scarce resources when all other parts of the Haitian economy needed investments, too?
Deforestation was a case in point. Halting or reversing the steady disappearance of Haiti's forests would reduce the risk of floods and avalanches and erosion but would require multiple interventions at once. Everyone knew, for example, that Haiti needed a new energy source, at least for cooking, that left the few remaining trees standing. Rural people felled trees to make charcoal, which they used for their own daily needs and sold as a cash crop. Alternative cooking
energies wouldn't solve the problem unless they truly became available to all and unless simultaneous investments were made in agriculture, food-processing plants, and fair trade.
energies wouldn't solve the problem unless they truly became available to all and unless simultaneous investments were made in agriculture, food-processing plants, and fair trade.
Just after the fourth storm struck, I wrote in the
Nation
that progressives needed to spend more time thinking about how to expand the Haitian economy by improving conditions for smallholder farmers while creating new job opportunities in manufacturing and public works (and, of course, in health care and education). Allow me to cite the
Nation
essay at length as it shows why doctors who listen to their patients can find themselves far afield from clinical medicine, and why it's important to understand Haiti's history in seeking to make (to use medical jargon) a diagnosis and treatment plan. Because Haiti's new prime minister took office on the day of the fourth storm, I started by referring to the challenges before her. These were rooted in Haiti's history:
Nation
that progressives needed to spend more time thinking about how to expand the Haitian economy by improving conditions for smallholder farmers while creating new job opportunities in manufacturing and public works (and, of course, in health care and education). Allow me to cite the
Nation
essay at length as it shows why doctors who listen to their patients can find themselves far afield from clinical medicine, and why it's important to understand Haiti's history in seeking to make (to use medical jargon) a diagnosis and treatment plan. Because Haiti's new prime minister took office on the day of the fourth storm, I started by referring to the challenges before her. These were rooted in Haiti's history:
Pierre-Louis, an economist new to politics, knows that these disasters are not purely “natural.” She also knows that the rural poor cut down trees to make charcoal because they have no choice. Only alternative fuels and reforestation, linked with other public works, and thus jobs, can reverse Haiti's deforestation. Jobs outside the agricultural sector are urgently needed if reforestation is to happen. This should make progressives slow to disparage new jobs in the tourist and apparel industries, dealt severe blows by the political unrest of the recent past.
That Haiti is a veritable graveyard of development projects has less to do with Haitian culture and more to do with the nation's place in the world. The history that turned the world's wealthiest slave colony into the hemisphere's poorest country has been tough, in part because of a lack of respect for democracy both among Haiti's small élite and in successive French and U.S. governments. During the first half of the nineteenth century, the United States simply refused to acknowledge Haiti's existence. In the latter half, gunboats pre-empted diplomacy. And in 1915 U.S. Marines began a twenty-year military occupation and formed the modern Haitian army (whose only target has been the Haitian people). After the fall of Duvalier in 1986, Washington
continued to support unelected, mainly military, governments. Indeed, it was not until after 1990, when Haiti had its first democratic elections, that assistance to the government was cut back and finally cut off. The decay of the public sectorâthrough aid cutoffs and neoliberal policiesâis one of the chief reasons Haiti, unlike neighboring Cuba, is unable to respond to hurricanes with effective relief.
continued to support unelected, mainly military, governments. Indeed, it was not until after 1990, when Haiti had its first democratic elections, that assistance to the government was cut back and finally cut off. The decay of the public sectorâthrough aid cutoffs and neoliberal policiesâis one of the chief reasons Haiti, unlike neighboring Cuba, is unable to respond to hurricanes with effective relief.
Haiti needs and deserves a modern Marshall Plan that rebuilds public institutions and creates jobs outside of the worn-down agricultural sector. Without one, it will have a hard time surviving the hurricane season. And next year will be worse.
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It was an easy prophesy: next year would be much worse. Through Zanmi Lasante, Partners In Health had created thousands of jobs in health care and education, and quite a few in construction, but we worried that they were not generative enough. What would a Marshall Plan for Haiti look like? Again, the agricultural sector needed massive investments to make farming more remunerative. Reforestation efforts also needed to be linked to real incentives for Haiti's smallholders. But what else deserved more support? Something in light industry, outside the perilously crowded and fragile capital city? What about fish farming? Support of women entrepreneurs? We turned to a small group of Partners In Health supporters with business experience and challenged them to launch a project called “1,000 Jobs for Haiti.” With their help, we created many pro-poor jobs in central Haiti.
But Haiti needed millions, not thousands, of decent jobs, and this meant intervening at a policy level. When Hillary Clinton accepted the job of Secretary of State, in January 2009, I was faced with an entirely new dilemma: should I join the government and work with her full-time on development issues? Red flags came up as I contemplated the role. Some of the people I conferred with raised doubts about my working full-time on policy. Others suggested that my work for Partners In Health, for which I'd always been a volunteer, might be seen as a conflict of interest rather than relevant experience. Even more troubling was another open question: Would I have to give up clinical medicine and teaching? I would surely have to
give up a certain freedom of expression in a highly partisan environment that was unpleasant for the conflict-averse. I couldn't imagine a life without clinical work, teaching, and writing whatever I felt was right; nor could I imagine a life without volunteer work for the destitute sick. Harvard Medical School had given me that freedom, and for perhaps the first time in my life I understood what a gift it was to be in academic medicine.
give up a certain freedom of expression in a highly partisan environment that was unpleasant for the conflict-averse. I couldn't imagine a life without clinical work, teaching, and writing whatever I felt was right; nor could I imagine a life without volunteer work for the destitute sick. Harvard Medical School had given me that freedom, and for perhaps the first time in my life I understood what a gift it was to be in academic medicine.
It was at this time, as I struggled with a decision that had been made public against my will,
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that President Clinton accepted the honorary post of UN Special Envoy for Haiti. He knew how anxious I was about failing to be the sort of effective bureaucrat that our government and the development enterprise deserved. He asked me to be his deputy at the United Nations, which had a huge, largely military, presence in Haiti. I would share the rank of UN undersecretary-general; each of us would be paid a dollar a year. This meant I would not have to give up my teaching and clinical work but might still have a voice in policy discussions about Haiti. I sought the approval of the dean of Harvard Medical School, who offered it without reservation. “You are linking research and training to service, and you involve your students and trainees,” he told me in August 2009. “That's what global health needs to be about.” My chief at Brigham and Women's Hospital was supportive for the same reasons.
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that President Clinton accepted the honorary post of UN Special Envoy for Haiti. He knew how anxious I was about failing to be the sort of effective bureaucrat that our government and the development enterprise deserved. He asked me to be his deputy at the United Nations, which had a huge, largely military, presence in Haiti. I would share the rank of UN undersecretary-general; each of us would be paid a dollar a year. This meant I would not have to give up my teaching and clinical work but might still have a voice in policy discussions about Haiti. I sought the approval of the dean of Harvard Medical School, who offered it without reservation. “You are linking research and training to service, and you involve your students and trainees,” he told me in August 2009. “That's what global health needs to be about.” My chief at Brigham and Women's Hospital was supportive for the same reasons.
Jeff Sachs helped me try to recruit Garry Conille, a Haitian physician schooled in the ways of the UN, to head the team. But Conille was otherwise occupied, the UN told us. I insisted on bringing Haitians onto the teamânone had been proposedâand colleagues at Partners In Health and the Clinton Foundation, led by Laura Graham, Clinton's current Chief of Staff. Graham was a force of nature: she invested uncountable hours in every issue she worked on. The bureaucratic challenges in this arena were significant, but a young Egyptian journalist, Jéhane Sedky, who had worked with Clinton in his previous role as Special Envoy after the 2004 tsunami, knew the ropes; she helped Jennie Block, a theologian and friend, and me pull together a team to help Clinton stand with Haiti. Our focus would be to “build back better” from the 2008 storms by pushing for long-term investments in sustainable development. We also sought to address
sharp deficits in public health and public education. Foreign assistance needed to be built back better, too, and our little team shared another aspiration: to move the focus from military assistance to development assistance, from security to human security, towards freedom from want.
sharp deficits in public health and public education. Foreign assistance needed to be built back better, too, and our little team shared another aspiration: to move the focus from military assistance to development assistance, from security to human security, towards freedom from want.
Three weeks later, I made my first trip to Haiti as a diplomat. Such travel was an experience familiar to President Clinton, but was, after hundreds of trips to Haiti, new to me. I moved about in an armored car and in a motorcade; I had a bodyguard (a Haitian-American policeman from Atlanta, who politely termed himself “a personal protection agent”). Clinton counseled me to focus on two broad agendas: the medical and public health issues I knew best but also the economic issues that influenced who got sick and who did not. I later learned that my trip had merited press coverage in the Miami
Herald:
Herald:
A prominent Harvard doctor and Haiti advocate completed his first visit to the Caribbean nation Tuesday in his new capacity as the United Nations' deputy special envoy.
Paul Farmer made the five-day visit as part of a follow-up trip that UN Special Envoy Bill Clinton made last month to Haiti, which suffered extensively last year because of back-to-back storms, food riots and a nearly five-month political crisis. The trip's goal: gauge how best to support the Haitian government in its national recovery plan.
During his visit, Farmer met with Haitian President René Préval and Prime Minister Michèle Pierre-Louis and other government officials, as well as with business leaders and representatives from the UN and nongovernmental organizations. Farmer also visited the Central Plateau region and Cap Haïtien, Haiti's second largest city, where he met with local leaders and tourism officials.
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This all sounded good, and I believed in the mission. Haiti had a terrible reputation internationally for dozens of reasons, most of them wrong. But it wasn't possible to claim that anti-Haitian propaganda was based purely on fantasy. After the public meetings mentioned in the press, I dragged the UN security team to visit the widow of a friend and colleague. Our lead surgeon, Dr. Josué
Augustin, had been murdered in Hinche on August 31. (Although I struggled to believe it was murder, and not an accident, what meager forensic evidence we had was clear enough.) It was impossible to begin a cheerleading campaign for Haiti as a safe place to invest when a protégé had been killed that same week. I wrote a eulogy for Josué:
Augustin, had been murdered in Hinche on August 31. (Although I struggled to believe it was murder, and not an accident, what meager forensic evidence we had was clear enough.) It was impossible to begin a cheerleading campaign for Haiti as a safe place to invest when a protégé had been killed that same week. I wrote a eulogy for Josué:
All of us are still reeling from the loss of Josué Augustin, whom we have known as student, intern, resident, colleague, and friend. Above all, we knew him as Dr. Josué, a level-headed and thoughtful surgeon and the driving force behind our collective efforts to make sure that surgery did not remain the “neglected stepchild” of our work in Haiti. Josué combined a rigorous pragmatism with a broad vision of what could be done to improve complex medical services, and surgery especially, in settings in which such endeavors are too often dismissed as impractical, not cost-effective, or even (absurdly enough) unnecessary. What this meant in terms of everyday practice was that he was there to round on patients, to scrub in, to organize a team of people (many of them from rural Haiti, others from far away) to provide care to those who would otherwise not have it. What this meant in terms of his own agenda was that he was always willing to engage people from all over the world (and especially from the United States and Cuba) who believed in his mission. It meant he was willing to go to where the pathology was, whether that meant Cange, Boucan Carré, Saint-Marc, Belladères, Petite Rivière de l'Artibonite, Lascahobas, or Hinche, where he was taken from us, and from his family and patients, just last week. What this means for us, beyond our grief, is that we must fight hard to make sure that Josué's vision of equitable surgical services for the poor is one that remains front and center, not just in Haiti but in those other regions, regions full of people in need, too readily written off as unsuitable for surgery. We honor Josué by making sure that such an important mission outlives him or any other one person.
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