Dr. Paul Farmer

Testimony to the Congressional Black Caucus: Focus on Haiti

27 July 2010

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1. Acute-on-chronic

The six-month anniversary of the earthquake, which many Haitians have taken to calling, simply, “the catastrophe,” will cause soul-searching in some circles, grim determination in others, and bitter recriminations from still other quarters. I will not contribute here to these veins of commentary, although we all know they’re important and inevitable. Instead I will use my time to comment on a few large but soluble problems now before us and to make two distinct and complementary recommendations. Indeed, most of these problems have long faced all those of good will who seek to stand in solidarity with the Haitian people, which is why, as physicians, we know that what happened on January 12th is aptly described as an “acute-on-chronic” event. Though by some reports and some “macro” indicators there had been slow improvements in Haiti in the year prior to the quake, the problems we’re struggling with today are longstanding, if much aggravated by the worst natural disaster to befall the world in recent centuries. Whether we look at health, education, potable water, or safe, affordable housing, we can draw similar conclusions: first, great weakness in the public sector makes it exceedingly difficult to deliver basic services at significant scale; second, not enough of the pledged earthquake relief has reached those in greatest need.

Although Haitians are rightly tired of having their country labeled “the poorest in the western hemisphere,” it is nonetheless true that the country has poor health indicators, was a few years ago deemed the most water-insecure nation in the Americas, has low levels of literacy, and now, with up to 1.6 million in IDP camps, has enormous, almost overwhelming, housing instability. Into the breach have come a large number of well-intentioned NGOs, which have sought, with some local success, to provide basic health and educational services, and, on an even smaller level, access to potable water and improved housing. I am myself from this sector, since I’ve been a life-long NGO volunteer and work for a U.S. medical school as a teacher and clinician. But I would like to argue here that my own earnest engagement in this arena has taught me that one of the primary tasks of development assistance, including that delivered by NGOs, must be to strengthen Haitian public-sector capacity, especially in the arenas of health, education, water, and housing—which some refer to as basic social and economic rights. Our historical failure to do so is one of the primary reasons that trying to help the public sector now is like trying to transfuse whole blood through a small-gauge needle or, in popular parlance, to drink from a fire hose.

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?

2. Why?

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.

3. What is to be done?

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.

This shift will not be a panacea for Haiti but could be coupled with a powerful and complementary focus on another movement of capital, this time from public to private and from wealthy to poor: a focus on job creation and on strengthening the hand of those trying to farm (and reforest) the land and also on young people, especially young women, living in poverty. We need a greater sense of urgency. And the most urgent task of all is the creation of jobs that will confer dignity to those in greatest need. As FDR said early in the Depression, “The Nation asks for action and action now. Our greatest primary task is to put people to work.”2 As it was during the Great Depression, there are innumerable public-works jobs imaginable, from reforestation and rubble removal to preparing for back-to-school (la rentrée), which must put kids back in schools, safe schools, with the books and uniforms they need and a nutritious lunch during the day. As for health, Haitians need a real health system. This will require a massive investment in new clinics and hospitals, staff to run them, and health insurance at a time when only 300,000 families have it. These are indivisible tasks, as FDR noted at the outset of the Depression: “Public health . . . is a responsibility of the state as [is] the duty to promote general welfare. The state educates is children. Why not keep them well?”

Job creation and improved health and educational services, with greater investment in the public sector: this should be a big part of the mantra. I do not mean to suggest that this transfer of capital, resources, etc., is easy. We know it’s not, because we’re in direct contact with the representatives of large multilateral and bilateral agencies, which have to follow laborious processes in order to disburse funds. But let us ask, in the face of urgent need, if we are well served by the fetishization of process now retarding the flow of capital into the hands of families in greatest need. The International Commission for the Reconstruction of Haiti, which is now being born, needs to be swift and nimble; the rules of the road for development assistance need to be rewritten, not to favor contractors and middlemen and trauma vultures, but to favor the victims of the quake. Right now there are shovel-ready projects, which could create tens of thousands of jobs and perhaps more. There are plenty of people living in poverty, including the market women who have never had access to capital or financial services and who have been working against an undertow of unfair trade policies, who are as entrepreneurial as anyone else in the world. Projects of all sorts can be greenlighted, but will move sluggishly if the funds seep into the ICRH too slowly and if projects cannot be moved forward because of strangling strictures on how the money is to be used.

People in this country know it’s possible to move forward with a sense of urgency. During the Depression, job creation and improved services from health care to education to rural electrification were the focus of many efforts. FDR, then the governor of New York, called for “workfare” and welfare through the Temporary Emergency Relief Administration (TERA). This call was made on August 28, 1931, and it was up and running by winter: The crisis had finally imposed some discipline of responsibility even on the Republican legislators, who with uncharacteristic docility did what the governor asked. (The New York Voters would overwhelmingly approve the bond issue in November 1932.) Faithful to romantic notions of rural life, Roosevelt had TERA subsidize the resettlement of as many unemployed as possible on marginal farmland, with tools and instruction on how to cultivate it. In six years TERA assisted five million people, 40 percent of the population of New York State, at a cost of $1,555,000. At the end of the period, 70 percent of these were no longer reliant on government assistance.

Later these lessons were taken to scale in many programs, including the Civil Works Administration, which created millions of jobs and moved billions into the public sector through public works and into the hands of the previously unemployed.

Certainly Haiti’s need is no less great than that faced by the States during the Depression. Let us hope it can build a more just tax base, even though its IRS, like its Ministries of Health and Education, has been destroyed. In the meantime, the world has responded generously and now it is incumbent upon us to move these resources into the hands of the Haitian people, especially those directly affected, in these two complementary ways. Again, this is not a choice between public and private sectors, any more than this is a choice between strengthening local agriculture and rebuilding infrastructure, but rather a plea to focus resource distribution on the poor and displaced by providing basic services and through job creation. There is no evidence whatsoever that this is an impossible mission.