BOOK REVIEW: 'Haiti After the Earthquake': Keeping the Tragedy in the Public's Attention Span As 'Compassion Fatigue' Takes Over

Reviewed by David M. Kinchen
BOOK REVIEW: 'Haiti After the Earthquake': Keeping the Tragedy in the Public's Attention Span As 'Compassion Fatigue' Takes Over

One of the most compelling parts of Paul Farmer's "Haiti After the Earthquake" (PublicAffairs, 456 pages, $27.99, illustrations, notes, index) comes in the "Other Voices" section after Dr. Farmer's eloquent narrative. 


On page 134 Dr. Evan Lyon   compares and contrasts the 7.0 quake that destroyed Port-au-Prince Haiti on Jan.12, 2010 with an 8.8 quake -- 500 times the force of the Haiti quake -- on Feb.27, 2010 that struck offshore in Chile: "...best estimates suggest that three hundred thousand people died in Haiti while fewer than six hundred died in Chile. Fewer buildings fell and fewer people died." On the first anniversary of the earthquake, 12 January 2011, Haitian Prime Minister Jean-Max Bellerive said the death toll from the quake was more than 316,000, raising the figures from previous estimates 


Farmer, born in the U.S. in 1959 and married to a Haitian, in my opinion attempts to explain -- or explain away --the reasons for this disproportionate casualty count, including hundreds of thousands of people who were severely injured and sustained amputations and other injuries, but he and the others aren't entirely successful.
BOOK REVIEW: 'Haiti After the Earthquake': Keeping the Tragedy in the Public's Attention Span As 'Compassion Fatigue' Takes Over


To his credit, in his sections on the country's dismal history, he blames the country's brutal rulers, including the Duvalier -- "Papa Doc" and "Baby Doc" -- dictatorships from 1957-1986. He calls for a more optimistic outlook on
Haiti's rebuilding efforts, citing the 2005 Katrina hurricane in Lousiana and Mississippi and the slow pace of rebuilding there.


Blaming the deaths on racism and colonialism on a country that has been technically independent since 1804 doesn't wash as much as would a report by a structural engineer  -- missing from this book -- on the building standards -- or lack thereof --  that allowed a quake to cause so much physical and human damage. Shoddy construction is one reason why Third World countries -- and Haiti, the poorest country in the Western Hemisphere, certainly qualifies as a failed, Third World nation  --  suffer disproportionate damage. First World, developed Chile suffered radically fewer casualties because it takes earthquakes seriously and has building codes that minimize earthquake deaths and injuries. This isn't blaming the victims, because Haitians have long been victims of their corrupt rulers.
Haitian National Palace
Haitian National Palace


Farmer describes the incredible suffering—and resilience—that he encountered in Haiti. Having worked in the country for nearly thirty years, as well as in Kigali, Rwanda, he explores the social issues that made Haiti so vulnerable to the earthquake — the very issues that make it an "unnatural disaster." 


These include the invasion and occupation of Haiti by the Woodrow Wilson administration in 1915, an occupation by the U.S. Marine Corps that lasted until 1934, when the last contingent of Marines departing during the Franklin D. Roosevelt administration. The invasion resulted in a Medal of Honor for Marine Capt. Smedley D. Butler, who later wrote a book "War Is A Racket" opposing Wilson's decision to invade the nation.
Paul Farmer
Paul Farmer
 
 
Complementing his account are stories from other doctors, volunteers, and earthquake survivors. Haiti is second only to India in  NGO (Non Governmental Organizations) devoted to aid, which may be part of the problem, suggests Farmer and others, including Jehane Sedky, who on page 356 writes that "decades of inexpensive food imports (coupled with food aid from well-meaning nonprofits) have destroyed agriculture in Haiti."

About six months after the quake, Farmer proposed some recovery strategies (see link: Farmer's testimony to congressional black caucus on aftermath of quake: http://s3.amazonaws.com/haiti_production/assets/21/Paul-Farmer_CBC-Testimony_27July2010_original.pdf) that are worth quoting at length:

Why the public sector? Before answering, I’m not suggesting here that NGOs and the private sector are not part of the solution; far from it. But there is a pragmatic and humble point to be made here: the profusion of NGOs—and some have estimated that Haiti, a veritable Republic of NGOs, has more of them per capita than any other country in the world—has not led to adequate progress in provision of basic services to all who need them nor to a functioning safety net for the poorest. Case in point: over 85% of primary and secondary education in Haiti is private, and Haiti is, as mentioned, plagued by illiteracy; over 500,000 school-age children were not in school prior to the earthquake.

There are transient ironies, too. Sometimes bursts of attention can improve a terrible situation; some blood does get through the too-small needle. Take water insecurity: by some reports, it has lessened since the earthquake led many groups to focus on bringing clean water to the displaced. One survey in Port-au-Prince suggested that diarrheal diseases had by last month dropped 12% below the pre-earthquake level. But is the massive importation of bottled water readily sustained? Is it the way to improve water security for all?

There is also a more philosophical point behind a plea for attention to the public sector: How can there be public health and public education without a stronger government at the national and local levels?


I have argued that the quake dramatically worsened a bad situation. I could focus on statistics, noting that some 17-20% of federal employees were killed or injured in the quake, or that 27 of 28 federal buildings were destroyed. And I would note that few public personnel were able to perform well within the buildings prior to the earthquake. Some of the best doctors and nurses I know are struggling to perform in the public sector without the tools of our trade—diagnostics and medications, for example, but also anything approaching adequate salaries. In a hearing like this one, it is important to ask why this is so, and I have previously done so before both houses of our Congress. It is not a pretty story, for the decline of Haiti’s already feeble civil service is tightly tied, and has been for a century, to internecine strife but also to U.S. policies. Other powerful countries have played unhelpful roles, too.

Let me take only the last decade. Beginning in 2000, the U.S. administration sought, often quietly, to block bilateral and multilateral aid to Haiti, having an objection to the policies and views of the administration of Jean-Bertrand Aristide, elected by over 90% of the vote at about the same time a new U.S. president was chosen in a far more contested election. How much influence we had on other players is unclear, but it seems that there was a great deal of it with certain international financial agencies, with France and Canada; our own aid, certainly, went directly to NGOs, and not to the government. Public health and public education faltered, as did other services of special importance to the poor. I noted in a book written in those years that the budget of the Republic of Haiti, nine million strong, wasn’t much different from that of the city of Cambridge, Massachusetts, with 100,000 citizens; neither amounted to a quarter of the budget of the Harvard teaching hospital, a single one, in which I trained and now work.

Without resources, it was difficult for public providers to provide; many left to work in NGOs, which did not have a mandate to serve all citizens, and others left the country altogether. Choking off assistance for development and for the provision of basic services also choked off oxygen to the government, which was the intention all along: to dislodge the Aristide administration.

But the coup, simply denied as such by some in the so-called international community, did not really take. The U.S.-selected caretaker government was unpopular, unrest continued to grow, and Port-au-Prince became the kidnapping capital of the world in spite of a very large U.N. presence. Again, the so-called forces of order, the police, were weak or corrupt—as pale a reflection of what the force should have been as were public health and public education.

Some efforts to reverse this ruinous policy of squeezing the public sector, which was often and correctly denounced by Congresswomen Lee and Waters and many other members of the CBC, have been palpable over the past year, although progress has been slow. And then came the earthquake, which further decreased the capacity of the public sector to provide meaningful services, leaving once again a growing number of NGOs and other non-state providers to fill the breach. Allow me to give two more data points: on January 27th, it was noted in the Washington Post that less than 1% of all U.S. quake aid was going to the Haitian government. (Almost as much went, even, to the Dominican government.) My colleagues at the U.N. are tracking these numbers, and also pledges made and disbursed, and here’s one of the latest: of $1.8 billion for earthquake relief sent to Haiti, less than 0.29% has so far gone to the government.

I argued here in 2003, in testimony to the Senate Committee on Foreign Relations, that it is difficult, without real and sustained commitments to strengthening the public sector— including its regulatory and coordinating capacity, so that the quality of the services offered by NGOs and others will not be all over the map—to monitor funds and to use them efficiently. This remains true today. Thus are the Haitian people still tasting the bitter dregs of the cup we prepared for them as we weakened, or failed to strengthen, the public sector over the past decades.

During these years, unfair international trade policies cut Haitian farmers off at the knees, accelerating the complex and vicious cycle of urban migration and deforestation that set the stage for the food insecurity that was to follow, for the extreme vulnerability to heavy rains and storms, and for the massive overcrowding and shoddy construction revealed to all late in the afternoon of January 12th.

This is where we are at the six-month mark, as hurricane season approaches. Less than five percent of the rubble has been cleared. People are going to camps for shelter and for other services that all of us humans need to get by. Gender-based violence worsens the “structural violence” to which the poor, in general, are subjected. The good news is that the enormous generosity and solidarity of the world after the earthquake was and is real: it’s estimated that more than half of all American households contributed to earthquake relief. Speaking as a volunteer for PIH, I can proudly announce that we have, along with the Ministry of Health, already broken ground on a huge new teaching hospital in central Haiti. We know from experience, as my colleague Loune Viaud will report, that it’s possible to get a great deal done in rural Haiti, and these services and jobs will also pull people out of the city and contribute to the decentralization so desperately needed.

But there needs to be a shift, especially in how we plan and deliver basic health, education, and other safety-net services: a commitment to move at least some of the assistance (including private money) into public hands, which has not been at all the favored approach to assistance to Haiti. This is increasingly recognized as the right thing to do, as Paul Weisenfeld, Haiti Task Team Coordinator for USAID, who reported the falling rates of water-borne diseases noted above, observed recently: “I think it’s key to us that if we’re going to have sustainability we are going to have to work through Haitian institutions, which requires strengthening them. Obviously [they’ve] been weakened tremendously by this earthquake, so at the same time that we implement reconstruction programs, we need to strengthen government institutions so that we can work through them.”1 We have also just worked with the American Red Cross to support performance- based financing of medical and nursing staff in Haiti’s largest public hospital. These efforts will not be easy, but they are necessary.

 
About the author
Dr. Paul E. Farmer is the UN Deputy Special Envoy for Haiti and Chair of the Department of Global Health and Social Medicine at Harvard Medical School. He is also Chief of the Division of Global Health Equity at Boston's Brigham and Women's Hospital, and co-founder of Partners In Health. Among his numerous awards and honors is the John D. and Catherine T. MacArthur Foundation's "genius award." He is currently the Kolokotrones University Professor at Harvard University, formerly the Presley Professor ofMedical Anthropology in the Department of Social Medicine at Harvard Medical School, an attending physician and Chief of the Division of Global Health Equity at Brigham and Women's Hospital in Boston,Massachusetts. He currently resides in Kigali, Rwanda. He is board certified in Internal Medicine and Infectious Disease. Farmer is one of the founders of Partners In Health (PIH), an international health and social justiceorganization. His work is the subject of Tracy Kidder's 2003 book Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World. He is editor-in-chief of Health and Human Rights Journal. Farmer was selected to head the U.S. Agency for International Development, but was met by controversy.  In August 2009, Paul Farmer was named United Nations Deputy Special Envoy to Haiti to assist in improving the economic and social conditions of the Caribbean nation. 
Websites: www.pih.org; www.publicaffairsbooks.com
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