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Tales from the Front

By Drs. Paul Farmer, Louise Ivers, and Claire Pierre

The Miami Herald
January 23, 2010

The vocabulary of clinical medicine is large and arcane, but a couple of concepts are useful in diagnosing what is happening in Haiti and in setting a path. In the coming weeks, there will be scores of prescriptions for Haiti, but there must also be diagnoses, too. What is going on right now would be described in clinical terms as an “acute-on-chronic” picture: Haiti’s majority has long been dealing with serious problems and to this has been added the acute injury of a massive earthquake affecting much of the country, most notably its most heavily populated areas.

If any kind of chronology can be imposed on a disaster of this magnitude, we are moving into the next phase, where rescue and relief operations continue — miraculous rescues of those trapped are still occurring, with one young girl and her brother pulled from rubble the other day and now recovering at the largest urban hospital — and are complemented by slowly coordinated efforts to bring food, drink, shelter, and basic medical services to the millions affected by the quake.

Some of the aid is starting to move, as repeat visits to Port-au-Prince’s general hospital reveal: In the space of less than a week, the hospital, run by local staff, has been assisted by scores of surgical and medical volunteers and has moved from no functioning operating rooms to a dozen that are busy all day, every day and throughout the night, too.

This disaster has brought together goodwill and interest in Haiti such that for the first time in the country’s history, there may soon be enough surgeons and trauma specialists. There are, of course, many kinds of trauma, and even those who escaped unscathed physically have lost friends and loved ones, to say nothing of material possessions.

Across the country, as people continue to search for missing family members and friends, a kind of numbness is giving way to grief. Rescue workers and medical personnel and ad hoc logisticians, most of them Haitians, will need a break, as some of them have been working nonstop for over a week. One of our collaborators is still in the clothes in which she escaped with her life from her home.


Everywhere here you see Haitians helping each other. Despite reports of violence, what strikes many of us is the overall sense of calm: Former President Clinton, after bringing surgical supplies to the general hospital, noted that no other people in the world would be so patient and calm in the face of so much suffering.

A young Haitian colleague, already on the faculty of Harvard Medical School, is organizing scores of volunteers from every class. People have opened their homes and yards, which are covered with makeshift shelters: The chronic problem of housing in Haiti is now worsened by the acute problem of half a million newly homeless.

In addition to cross-class cooperation, it is clear that the Haitian diaspora, which scattered across North America and Europe (and even Rwanda, where a small group of Haitians is busy raising funds) has a lot to offer beyond material assistance. One post-surgical ICU doctor, Dr. Ernest Benjamin, wrote to his home institution in New York to say that “at last this is starting to look like a functioning hospital”.

He and other Haitian professionals living in the United States — Haitian physicians and nurses are a powerful force there — have much to offer a large-scale rebuilding effort if it is coordinated with efforts to rebuild national institutions.

Another helpful notion from medicine is the pledge to “do no harm”. Knowing what not to do is not the same thing as knowing what to do — who can be sure of what to do when nothing of this scale has been registered before? — but it is important nonetheless to learn from years of international aid to Haiti.

First, long-term lack of coordination of relief and reconstruction efforts will be costly. Competition between self-described donor nations is worse than unhelpful. Even now, there is bedlam as medical teams arrive with excellent skills and intention, but insufficient coordination.

The many clinicians now in the country need to work together as a team.

One potential model of recovery for Haiti is the nation of Rwanda. After the 1994 genocide, Rwanda was overwhelmed by the international helping class, which included, in addition to many people of good will, a flock of trauma vultures, consultants and carpetbaggers. Under the strong leadership of the nascent government, including now-President Paul Kagame, leaders insisted that recovery and reconstruction aid be coordinated by the central and district governments. A number of nongovernmental organizations left Rwanda, but most would argue the decisions made then have helped to create a new model of collaboration between public and private actors, and contributed to Rwanda’s remarkable post-genocide stability and growth.

The government of Rwanda has made a generous financial gift to the people of Haiti.

Second, neglecting the immediate-term needs in favor of the long view is a mistake. People need food, water, shelter and sanitation in the days and months to come, to complement the emergency medical care that has been dispatched.

Third, those who wish to help in the next few days would be wise to hold off on most in-kind donations. Some of these will surely be needed soon, but the best thing to do right now is to send cash to organizations that have deep connections to Haiti and can draw on local knowledge and local hands to respond to the immediate needs of the injured, homeless, and sick.


Fourth, we must do no harm in resettlement efforts. Housing will be an enormous challenge, and will require the best minds on the planet. We need to avoid creating intermediate-term camps that become slums.

Fifth, we must make sure that deportation of Haitians from the United States and elsewhere stops.

Prescriptions for Haiti will be bountiful from outside, but we must ensure that the prescriptions are correct. Haiti needs a different kind of assistance, one built on solidarity and respect and rooted in what the Haitian people want for themselves. Assistance offered now must develop food sovereignty for Haiti and investment in the rural area, now seeing an influx of those displaced from the capital.

The next few weeks will reveal some sense of the long-term prognosis for the reconstruction of Haiti.

There is already talk of a $12 billion rebuilding tab.

Haiti needs and deserves a Marshall Plan. We need a reconstruction fund that is large, managed transparently, and creates jobs for Haitians, grows the Haitian economy and uses a rights-based approach that is pro-poor and based on something far different from the charity and failed development approaches that have marred interactions between Haiti and much of the rest of the world for the better part of two centuries.

As physicians working in Haiti, we know first-hand that Haiti itself will be the casualty soon if we do not help build back better in the way envisioned by Haitians themselves. The authors are all physicians working with Partners In Health/Zanmi Lasante in Haiti and teach at Harvard Medical School.

Dr. Farmer serves as United Nations deputy special envoy for Haiti under Bill Clinton.