Haitian Child

Haitian Child

Wednesday, December 5, 2012

Review Notes - Haiti after the earthquake by Paul Farmer

Paul Farmer, MD is a co-founder of Partners in Health (PIH), an organization devoted to help improve the welfare of the poor in the world. PIH (Zanmi Lasante in Kreyol) has had a major impact on health care in Haiti for 25 years and is now the largest provider in the country. PIH has helped build or refurbish about 60 hospitals and clinics and employs about 5,500 Haitians.

This blog is not a critical review of the content of the book or his writing. Rather, this blog is a selection of informative ideas that I culled from from the book - Thinking Points. 

Farmer opens the book with an invocation to the indefatigable spirit of the Haitian people and he chose Neg Mawon as the symbol of this spirit. Neg Mawon is a free man, a former slave, who has cast off the shackles of oppression. The statue of Neg Mawon survived the earthquake and stands in the center of Port au Prince.

Neg Mawon. Photo courtesy of Women in Charge

Farmer writes that as a physician there is a continuing tension between serving those right in front of you and seeking to reduce the longer-term risk of others ending up in the same situation. He refers to this as the tension between Praxis and Policy. Health care workers make good decisions one patient at a time (good Praxis), but the social situation never changes and the patients never stop coming (public Policy problem). As an example, Farmer quotes a physician with Medicines Sans Frontiers (MSF) who wrote that after the start of the cholera epidemic, Haitians were deluged with text messages to wash before eating but they were still obliged to bathe their children in largely untreated sewer water.  

Farmer reports that in other parts of the world where large populations suffered natural or war-related disaster, that the average displaced person spends over a decade in a "temporary" settlement.  

Haiti is a Republic of NGOs. Even before the quake there were more Non-Governmental Organizations (NGOs) per capita in Haiti than in any other country except India. Farmer suggests that aid from NGOs has had much less impact than desired because the NGOs do not report to the government, there is no communication and collaboration between NGOs, and that for some of the NGOs, the mission of the organization, albeit intended as well meaning, has served other non-Haitian, non-productive goals, and has actually created problems. Farmer references "Alms Dealers," an essay by Philip Gourevitch, in the New Yorker. Gourevitch wrote, NGOs are "Sowing horror to reap aid, and reaping aid to sow horror."  

The Duvalier dictatorship ended in 1986. Notwithstanding billions of dollars in AID, there has been little if any progress in Haiti. Farmer asks the question, What has gone wrong in four decades? One of his answers is that only a tiny percent of the aid money has been under the control of the government. Without money, the government has been powerless to help. Farmer points out that in 2002, the government budget for Haiti, a country of almost 10 million, was a quarter of the budget for the Harvard University hospital where he works!

Haiti was once the world's leading exporter of sugar, but now is a net importer. A local refinery produces only 2% of the sugar that is consumed in the country. Farmer asks what happened to this thriving industry? One of his answers is that less expensive and foreign subsidized sugar has undercut the local market. The same phenomena happened after the quake with rice, another important local crop. 

The victims should be allowed to speak for themselves. For their entire history, others have routinely spoken for the common Haitian. First as slaves, then as free men but under the oppression of a series of dictators, then as citizens but without an effective government and at the mercy of bureaucratic and often ineffective NGOs. 

Farmer makes some suggestions to turn the corner and to make progress. He recommends that NGOs be integrated into the public sector. The plans and operations of the NGOs should be approved by the government. He also recommends that a freely elected democratic government should be allowed to control the humanitarian aid money and to pursue reconstruction policies made by the elected members. 

Farmer writes very favourably about former President Bill Clinton's support for Haiti. Two of Clinton's phrases resonated with Farmer. Build Back Better and Get Stuff Done (GSD). Farmer took the GSD message to heart. PIH will soon open a new modern state-of-the-art teaching hospital in Mirebalais, the largest town in Haiti's Central Plateau.   

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