Haiti after the Earthquake, Paul Farmer (and many others)

Public Affairs, New York, 2011, price US$27.99, GBP 14.99

For someone who has spent nearly thirty years founding the largest and most effective medical NGO in Haiti, with a radical global health vision beyond almost anyone in his field, you would expect Paul Farmer to have something to say post-earthquake. As ever, he does and just as importantly do the twelve essayists – all friends, family and colleagues – who take up the final 100 pages of this discursive diary.

It’s a fascinating and essential read – like all Paul Farmer on Haiti – but not for the usual reasons. Seventeen years on, gone is the rage and clarity of his singular voice in the Uses of Haiti; six years on there is none of the expertise or erudition of Pathologies of Power. This is a more nuanced, if no less passionate, book, raising questions, sometimes without answering them at all, sometimes only addressing them very generically. But then as a clinician, teaching doctor or writer, Paul Farmer has always expected his patients, students or readers to think for themselves.

Those who know nothing of Paul Farmer and his work, should read this book in conjunction with the decade of hindsight afforded by Mountains Beyond Mountains (Tracy Kidder, Random House), a book about him, his organization, his ground-breaking medical NGO, Partners in Health/Zanmi Lasante (PIH/ZL) and the Haitians who have forged his philosophy. Those who know of him, some, perhaps dismayed by his acceptance of a role as UN Deputy Special Envoy to Haiti under Bill Clinton in 2009, need to read it by way of explanation and reconsider.

Here, in UN mode, he is often as frustrated as you might be – dispensing with UN protocol, passports and bodyguards to get to where he has come from, to the ordinary Haitians who enabled him to teach us so much. Here too, he is constantly deploying experience and understanding to at least try to leverage his new status into something more — “a voice in policy discussions” — even if, as he seems to warn himself as much as his audience at the beginning of this book, there may be a price to pay – “a certain freedom of expression.”

This is Paul Farmer the diplomat, or perhaps worse at times, the politician, Bill Clinton’s “plus one,” asking plenty of questions as he takes us through his year, with recollections and observations designed, in his slightly obtuse phrase, to advance “the process of discernment.” Those who know him or his writing will however still recognize the essential Paul Farmer, academic clinician, development guru and now father, taking advantage of the ultimate “teachable moment” – the earthquake itself.

Here he demonstrates through his firm grasp of Haitian history, distant and recent, why the earthquake was so devastating; why billions of dollars in development aid has so singularly failed to improve the lot of the vast majority of Haitians to date; what needs to be done differently this time in what could and should be a unique opportunity to, in the ill-defined campaign-style slogan of his UN boss, Bill Clinton, “build back better.”

Paul Farmer does define the phrase, if only generally. To him it means a total commitment to a massive investment in public sector social provision and bolstering rather than blaming a Haitian government, weakened by years of donor bypassing. All this, he argues, needs to be done within the envelope of an unswerving preferential option for the poor in health care, water supply, sanitation, housing, education and jobs.

Unlike so many others, we see Paul Farmer doing something to advance this agenda – personally practicing what he preaches, man and message merged. When he arrives in Port-au-Prince just over 48-hours after the earthquake having already put in an appearance at the UN in New York with Bill Clinton, he goes straight to the main public hospital he knows so well. This is the flagship, or rather low-in-the-water barge of the Ministry of Health, with which PIH/ZL has worked for more than two decades.

Not for Farmer, the super medical facilities of the all-purpose emergency field units of the massively-funded emergency medical NGOs or later the 12-operating theatres of the hospital ship the USS Comfort. They, he points out, can chose who they treat, are accountable to no one and will leave within weeks. Farmer and his cohorts – many of whom he trained — go straight to the hospital for all Haitians. Here he outlines a pre-existing condition with 25-years of perspective, explaining why it, and the Ministry of Health that run it, are in the state they are in, trying to provide some semblance of medical care for 10 million people on $45m a year.

Here is the nub of what he terms praxis and policy – the understanding that the manner and method by which you treat the patient in front of you today, what you prescribe, and the mechanism and philosophy by which you provide it, will have consequences for those you will see tomorrow, for the delivery and availability of health care next year and beyond. Do no harm, the old medical maxim rules, but you can, he shows, do a lot of good for the individual, the institution and even the country simultaneously as well.

So with the outbreak of the cholera epidemic we see him persuade the UN to come clean about the cause – Nepalese troops – then argue for what he terms the “maximalist” approach, integrated prevention and treatment, including vaccination. Here too, Paul Farmer has not just form but force. More than a decade back the equivalent of the minimalists argued it was pointless trying to treat HIV/AIDS sufferers in Haiti. They were impossible to reach, they would not take their medicines, they were poor, illiterate, they were, in short, in the subliminal message you so often hear, not worth the effort or resource.

With the Clinton Global Health Initiative providing the cheap drugs, Farmer and PIH/ZL proved the global health experts totally wrong – just as they had done by pioneering a treatment regime for drug-resistant TB a few years before. Working with a robust network of community health promoters, they achieved successful HIV treatment rates and outcomes in the central Haiti comparable to anything in developed world.

Paul Farmer could give you several chapters on the cholera context too. It’s not just that Haiti is the least water-secure country in the hemisphere, a cholera or typhoid epidemic waiting to happen. He can tell you exactly why that is the case. Try starting with the blocking of massive IDB loans for major water and sanitation projects when President Aristide was re-elected President in 2000. Pure spite, as Randall Robinson, might say.

Context — poverty, homelessness, malnutrition — of individual patient, applies to the institutional body politic too. For Farmer the two are inseparable, for he is the antithesis of the relief or aid officials for whom diagnosis starts when they step off the plane in Port-au-Prince, who invariably starts prescribing without listening to a word the patient — or the government — says.

The same principles apply to the aid and reconstruction donor fora where as Bill Clinton’s deputy, Farmer is often rubbing shoulders somewhat uncomfortably with heads of state, foreign ministers and the top officials of the multilateral financial institutions. Realizing there will be no ordinary Haitians voices at the infamous Haitian Donors Conference at the UN on March 31 in New York, he persuades Michele Montas-Dominique, one of the essayists in this book, to organize a massive listening project in Haiti, the Voice of the Voiceless.

Whether anyone listened let alone acted on the opinions of hundreds of ordinary Haitians seems unlikely – a fact borne out by so much of the reconstruction procedures and priorities to date. Michel Montas-Dominque records their reconstruction priorities in her excellent contribution in this book (if you read only one chapter read this. Sim Pas Rele is just 13-pages and you’ll learn a lot of Haitian Kreyol as a bonus).

Although Farmer is a novice in such global fora, he learns fast, as he has in every other field in which he has immersed himself. Working the corridors, he fleshes out his own definition of his new role as an international development envoy: a bridge between two worlds. Sadly, despite repeated references to “divisions” and “disagreements” that might help explain why we are where we are in Haiti now, and what we have to overcome, we do not learn the detail.

Part personal diary, part moral reflection, part general thesis, this is Paul Farmer’s public, but as private as you get from him, perspective on the January 12 2010 Haitian earthquake and its consequences. His poor family – his Haitian wife Didi focuses on gender-based violence in the camps in her chapter – barely get a look in from Farmer’s nominal home on the other side of the world in Rwanda.

Even when they do, they don’t. “Dad, can we not talk about cholera at the dinner table?” pleads his eldest daughter Catherine on one of those occasional trips back to Kigali. “No, not yet,” writes Farmer heartfeltly obsessed by “our failure to bring all the tools of our trade to bear on the epidemic.”

In some ways this book is as unpolished and raw as Haiti itself, yet like the country and its history, is an invaluable tool in the understanding of the rights, sovereignty and justice so denied to so many Haitians for so long. Those looking for a detailed manifesto will be disappointed. Those seeking an observed and expository narrative with a broad brush overview from a real visionary will be compelled. The breadth of Farmer’s reading and his consequent ability to make connections is reflected in 43-pages of extensive footnotes. Read them as a separate chapter. Some are short essays that go some way to compensate for the specifics lacking in the text.

Underpinning the book is an age-old dilemma many have faced: whether to step onto a big stage to further ideals that are often ancillary, sometimes even antithetical to the considerations of the big stage-managers themselves; to go on treating the individual victims, or to try and cure the institutional causes of the problem. If anyone can manage to shunt the international crisis caravan of donors, NGOs, the UN and multilateral financial institutions by force of logic, experience and energy, is the indefatigable Paul Farmer.

But the risks are obvious. Many have stepped onto larger stages, and been compromised by the institutions they moved into rather than affecting the change they thought they brought. The jury on that, on the risk to Paul Farmer’s vision and its implementation, is still out. Harvard, Haiti, Rwanda, PIH/ZL, will keep him grounded. The UN role is part-time, unpaid and temporary. The rest of Paul Farmer’s many roles — teacher, academic, global health pioneer, and infectious disease doctor – are, thank goodness, very permanent.

In some ways the book we await is that written when Paul Farmer’s UN term ends: when he can really assess his impact on the aid and development process, when he is completely free to say what he thinks about others, when he has seen what Haiti looks like five years on, various scenarios for which he imagines in his last chapter “Looking Forward, Looking Back.”

Will Haiti, five years on be in the “reconstruction” intensive care ward or the “construction” rehabilitation ward? In 2015, will Haiti once again have become the equivalent of so many poor patients arriving at national hospital, ending up “lost to follow up”? Will the chronic symptoms, as opposed to the acute, be diagnosed correctly and treated by those with the interests of the vast majority of Haitians, the poorest, at heart? Can the limited but tangible socio-economic progress made in 2009, after the hurricanes of 2008 before the earthquake of 2010, be recovered and accelerated? Start taking notes for your sequel, Doktor Paul. You need to write, we all need to know.